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PHYSICIANS  AND  SURGEONS 

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Operative  Surgery 


FOR  STUDENTS  AND  PRACTITIONERS 


JOHN  J.   McGRATH,   M.D. 

Clinical,  Professor  of  Surgery,  Fordham    University;    professor  of  Operative 

Surgery,  New  York  Post-Graduate  Medical  School;   Consulting  Surgeon 

TO  THE  People's  Hospital;   Visiting  Surgeon  to  the  Harlem  and 

New  York  Foundling  Hospitals;   Fellow  of  the  New 

York  Academy  of  Medicine;  Member  of  the 

American  Medical  Association. 


FOURTH  Revised  and  Enlarged  Edition 


mftb  364  Ulliisttations,  UncluMna  ffulUpacie  Color 
an&  1balt*=tone 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  Publishers 

1913 


1  Dii 


COPYRIGHT,  1902 

COPYRIGHT,  October,  1905 

COPYRIGHT,  October,  1909 

COPYRIGHT,  November,  1913 

BY 
F.   A.   DAVIS   COMPANY 

Copyright,  Great  Britain,     All  Rights  Reserved 


Philadelphia,  Pa.,  U.  S.  A. 

Press  of   F.  A.  Davis   Company 

1914-16  Cherry  Street 


PREFACE  TO  FOURTH  EDITION. 


Since  the  publication  of  the  last  (third)  edition  many 
important  advances  have  been  made  in  surgical  technique.  These 
have  been  incorporated  and  fully  described  in.  the  present  edition. 
Much  new  matter  and  many  new  illustrations  have  been  added. 
The  minor  operations  have  also  been  carefully  considered  and 
accurately  described  in  this  edition. 

In  the  selection  of  individual  operations  the  author  has 

been  guided  by  his  own  extensive  experience  in  choosing  those 

which  have  appeared  to  him  to  best  accomplish  the  objects  in 

view. 

John  J.  McGrath. 


(iii) 


PREFACE  TO  THIRD  EDITION. 


In  the  preparation  of  the  third  edition  particular  care  has 
been  given  to  the  section  on  abdominal  surgery.  This  section  has 
been  entirely  rewritten  and  much  valuable  new  matter  added. 
Many  of  the  abdominal  operations  range  in  the  class  of  emergency 
oj)erations^  for  example,  for  acute  appendicitis,  for  strangulated 
hernia,  anastomosis  of  bowel,  etc.  These  operations  to  be  suc- 
cessful must  be  undertaken  without  delay  and  special  attention 
has  been  devoted  to  the  accurate  description  of  the  technique  of 

these  procedures. 

John  J.  McG-eath. 


(iv) 


CONTENTS. 


PAET  I. 

PAGE 

General  Consideeations   1-39 

Ansesthesia:  General  anesthesia,  1;  incomplete  general  anaesthesia  4;  ad- 
ministration of  ana&sthetics,  5;  intratracheal  anassthesia,  9;  local  anaes- 
thesia, 11;  infiltration  method,  13:  Schleich  infiltration  method,  13;  regional 
anaesthesia,  14;  spinal  anaesthesia  (analgesia)  by  stovain  or  tropacocain,  15. 
—Division  of  Tissues:  Division  of  soft  parts,  15;  division  of  bone,  16. — 
Hemorrhage:  Means  to  arrest  hemorrhage,  17;  natural  arrest  of  hemor- 
rhage, 17;  artificial  arrest  of  hemorrhage,  17;  treatment  of  severe  hemor- 
rhage, 24. — Suture  of  the  Tisues:  Suture  of  the  skin,  33;  intracuticular 
suture,  33;  suture  of  muscle,  34;  suture  of  tendons,  35;  suture  of  nerves, 
35;  suture  bone  and  cartilage,  35;  suture  of  serous  surfaces,  bowel,  etc.,  37. 


PART  II. 
Head  and  Face    40-201 

Head:  Surgical  anatomy  of  the  head,  40;  of  the  scalp,  40;  -cf  the  skull,  41;  of 
the  dura  mater,  53;  brain,  56;  of  the  pia  mater,  65;  cranio-cerebral  topog- 
raphy, 65. — Operations  upon  the  Head:  Trephining,  70;  for  depressed  frac- 
ture of  the  skull,  72;  for  intracranial  hemorrhage,  74;  decompression,  79; 
temporal  decompression  (Gushing),  80;  cerebellar  decompression,  82:  crani- 
otomy, osteotegumentary  flap  method,  82;  in  parietal  region  to  expose  motor 
area,  etc.,  84;  to  expose  cerebellum  and  other  parts  in  posterior  fossa 
(Gushing),  92;  exposure  of  one-half  of  cerebellum  (Krause),  94:  for  abscess 
of  brain,  96;  puncture  of  brain  and  ventricles  for  diagnostic  purposes,  97; 
for  tapping  lateral  ventricles,  98;  permanent  drainage  of  lateral  ventricles 
(Krause),  98;  craniectomy  (linear  craniotomy),  100;  trephining  of  frontal 
sinus,  101. — Middle  Fossa  of  the  Skull:  Extirpation  of  Gasserian  ganglion 
(Hartley-Krause),  105;  Gushing,  109;  Rose-Andrews,  111. — Mastoid  Region 
and  Ear:  Surgical  anatomy  of  mastoid  region,  113:  anatomy  of  the  ear,  116. 
— Operations  upon  the  Mastoid,  etc.:  Paracentesis  of  drum  membrane,  122; 
Wilde's  incision,  122;  to  open  and  drain  antrum,  122:  for  thrombosis  sigmoid 
sinus,  126;  for  cerebellar  abscess,  127;  for  extradural  abscess  in  middle  fossa, 
128;  for  temporo-sphenoidal  abscess,  128. — Face:  Surgical  anatomy  of  face, 
129;  of  skeleton  of  face,  130;  of  mouth,  132;  side  of  face,  136;  pterygo-maxillary 
region,  137. — Operations  upon  the  Face:  Resection  of  upper  jaw,  143;  total 
resection  of  both  superior  maxillae,  148;  to  drain  antrum  of  Highmore,  148; 
resection  of  half  of  lower  jaw,  149;  resection  of  half  of  body  of  lower  jaw, 
152;  resection  of  entire  body  of  lower  jaw,  153;  resection  of  part  of  body  of 
lower  jaw  (in  continuity),  154;  resection  of  part  of  body  of  lower  jaw  (not 
in  continuity),  156;  resection  of  temporo-maxillary  articulation,  156;  division 
of  second  and  third  branches  of  trifacial  nerve  (Kronlein-Lucke),  157; 
operation  upon  the  peripheral  branches  of  the  trifacial  nerve,  158:  injection 
of  the  trunks  and  peripheral  branches  of  the  trifacial  nerve,  159. — Gongenital 
Deformities    of    Face:      Development    of    face,    161;    formation    of    palate. 


(V) 


vi  CONTENTS. 


PAGE 

169;  teeth,  170;  tongue,  170;  deformities  of  face  171;  deformities  in  which 
frontal  plate  is  concerned,  172;  lateral  clefts  of  the  upper  lip,  and  alveolar 
process  and  cleft  palate,  172;  median  clefts  and  notches  of  the  upper  lip, 
177;  lateral  nasal  cleft,  178;  oblique  facial  clefts,  178;  deformities  in  which 
the  first  visceral  arch  is  concerned,  179;  transverse  facial  clefts,  179;  median 
clefts,  of  lower  lip,  lower  jaw,  and  tongue,  179. — Operations  for  Harelip, 
Cleft  Palate,  etc.:  Operations  for  harelip,  179;  operations  for  incomplete 
harelip,  181;  operations  for  complete  harelip,  184;  operations  for  single,  com- 
plete harelip  with  cleft  of  alveolar  process  and  advancement  of  the  inter- 
maxillary bone,  185;  operation  for  double  harelip  without  a  prominent  ad- 
vanced intermaxillary  bone,  186;  operation  for  double  harelip  with  promi- 
nent advanced  intermaxillary  bone,  187;  operation  for  cleft  palate,  189. — 
Operations  upon  the  Lips:  Excision  of  whole  lower  lip,  196;  restoration  of 
lower  lip,  196;  Dieffenbach-Jaesche,  197;  Bruns,  198;  Langenbeck,  199; 
Estlaender,  200;  restoration  of  upper  lip,  201;  Estlaender,  201;  Dieff en- 
bach's  Wellenschnitt,  201;  Bruns,  201. 


PAKT  III. 
Neck  and  Tongue   202-370 

Surgical  Anatomy  of  Neck:  Deep  cervical  facia,  202;  back  of  the  neck,  205; 
side  of  the  neck,  205;  anterior  triangle,  208;  posterior  triangle,  208;  sterno- 
mastoid  region,  208;  inferior  carotid  triangle,  209;  superior  carotid  triangle, 
210;  submaxillary  triangle,  211;  lingual  triangle,  212;  occipital  triangle,  212; 
subclavian  triangle,  21.3;  front  of  the  neck,  214;  hyoid  bone,  214;  supra- 
hyoid region,  216;  infrahyoid  region,  216;  laryngeal  region,  218;  thyroid 
gland,  219;  parathyroid  bodies,  220;  suprasternal  region,  220;  blood-vessels 
of  the  neck,  221;  common  carotid  artery,  221;  internal  carotid  artery,  223; 
external  carotid  artery,  224;  internal  jugular  vein,  225;  subclavian  artei^, 
226;  inferior  thyroid  artery,  227;  superior  thyroid  artery,  227;  vertebral 
artery,  228;  cervical  sympathetic  nerves,  228;  cervical  lymph-nodes,  229. — 
Operations  upon  the  Neck:  Ligation  of  blood-vessels,  230;  common  carotid 
artery,  230;  external  carotid,  232;  internal  carotid,  232;  subclavian  artery, 
233;  lingual  artery,  234;  superior  thyroid  artery,  234;  inferior  thyroid  artery, 
235;  facio-hypoglossal  nerve  anastomosis,  236;  resection  of  cervical  sym- 
pathetic (Jonnesco),  237;  cervical  adenectomy,  240. — Operations  upon  the 
Trachea  and  Larynx:  Tracheotomy^  244;  tampon  of  trachea,  244;  high 
tracheotomy,  245;  low  tracheotomy,  247;  median  tracheotomy,  247;  transverse 
laryngotomy,  248;  thyrotomy,  248;  laryngectomy,  250;  extirpation  of  half 
of  the  larynx,  254. — Operations  upon  the  Thyroid  Gland:  Partial  extirpa- 
tion, 255;  enucleation,  258;  ligation  of  thyroid  arteries,  260;  external 
oesophagotomy,  260. — Operations  upon  the  Tongue:  Amputation  of  tongue 
(Kocher),  262;  extirpation  of  tongue  with  ligation  of  both  lingual  arteries, 
265;  extirpation  of  portion  of  tongue,  266;  amputation  of  tongue  (Regrioli- 
Billroth),  266;  extirpation  of  tongue  through  floor  of  mouth  with  division  of 
lower  jaw,  267;  Sedillot,  267;  Langenbeck,  268;   Billroth,  269. 


PAET  IV. 
TiiOEAx    271-320 

Surgical  Anatomy  of  Thoracic  Wall:  Skeleton  of  thorax,  271;  muscles  of 
chest  wall,  274;  fasciae  of  chest,  274;  internal  mammary  artery,  275;  dia- 
phragm, 276. — Regions  of  Chest:  Sternal  region,  277;  upper  anterior  pec- 
toral region,   277;   clavicular  region,   278;   infraclavicular  region,   279;   mam- 


CONTENTS. 


PAGE 

mary  region  (breast),  280;  lower  anterior  pectoral  region.  282;  lateral  pec- 
toral region,  282. — Mediastinum  and  Contents:  Pericardium,  283;  heart, 
284;  thymus,  287;  arch  of  aorta,  287;  pneumogastric  nerves,  288;  phrenic 
nerves,  289;  trachea,  289;  oesophagus,  288;  thoracic  aorta,  292;  vena  azygos, 
292;  vena  hemiazygos,  293;  thoracic  duct,  293;  innominate  artery,  293;  left 
common  carotid  and  subclavian  arteries,  293. — Pleura:  Limits  of  pleura 
indicated  by  lines  upon  chest  wall,  294;  anterior  edge  of  pleura,  294;  lower 
edge  of  pleura,  29G;  dome  of  pleura,  298. — Lungs:  Root  of  lung,  299;  lung. 
300. — Operations  upon  the  Breast:  Incisions  for  abscess  of  breast,  301; 
extirpation  of  tumors  (fibroids)  from  mammary  gland,  302;  amputation  of 
breast  (Halsted-Meyer),  302;  skin  grafting  (Thiersch),  306;  ligation  of  in- 
tercostal artery,  307;  ligation  of  internal  mammary  artery,  307. — Opera- 
tions upon  the  Heart:  Paracentesis  pericardii,  307;  pericardiotomy,  308; 
pericardiorrhaphy,  309;  cardiorrhaphy,  309. — Operations  upon  the  Pleura: 
Thoracentesis,  315;  thoracotomy,  316;  thoracotomy  (Lloyd),  317;  thoracec- 
tomy  (Estlaender),  318;  pleurectomy  (Fowler),  319. 


PART  V. 
Abdomen  and  Back 321-544 

Abdomen:  Diaphragm,  321;  posterior  wall  of  the  abdomen,  322;  antero-lateral 
wall  of  the  abdomen,  323;  superficial  vessels  of  abdominal  wall,  324;  mus- 
cles of  the  antero-lateral  wall,  324;  fascia  transversalis,  328;  parietal  peri- 
toneum, 328;  deep  vessels  of  abdominal  wall,  329;  regions  of  the  abdomen, 
330. — The  Back:  Muscles  of  the  back,  333;  erector  spinas  muscle,  334;  quad- 
ratus  lumborum  muscle,  335;  lumbar  fascia,  335;  psoas  and  iliacus  muscles, 
336;  spinal  column,  etc.,  336. — Operations  upon  the  Abdomen:  Laparotomy, 
339. — Operations  for  Umbilical  and  Ventral  Hernia,  etc. :  Umbilical  hernia, 
347;  ventral  hernia,  352.— The  Stomach:  Surgical  anatomy  of  the  stomach, 
355.— Operations  upon  the  Stomach:  Plication  of  the  gastrohepatic  liga- 
ments (Beyea),  360;  gastroplication,  362;  infolding  of  wall  of  stomach  for 
ulcer,  364;  gastrotomy,  364;  pyloroplasty,  370;  Heinecke-Mikulicz,  370; 
Finney,  372;  gastrostomy,  375;  Ssabanajew  and  Franck,  376;  Witzel,  376; 
Kader,  379;  gastrorrhaphy,  380;  gastroplasty,  381;  gastro-gastrostomy,  382; 
gastrectomy,  384;  partial  atypical  gastrectomy,  384;  partial  cylindrical 
gastrectomy,  385;  pylorectomy,  385;  Billroth,  386,  390;  Kocher,  390;  Hart- 
mann  gastrectomy,  393;  Mayo,  398;  complete  gastrectomy,  400.— The  Small 
Intestine:  Surgical  antomy  of  the  small  intestine,  406. — Operations  upon 
the  Small  Intestine:  Enterotomy,  411;  enterostomy,  412;  jejunostomy 
(Maydl),  414;  Witzel,  416;  enterorrhaphy,  416;  enterectomy,  421;  end-to-end 
anastomosis,  423;  suture  (McGrath),  384;  Mounsell,  427;  Connell,  429; 
Murphy  button,  431;  side- to-side,  lateral  anastomosis,  433;  suture,  433;  with 
clamps,  436;  with  Murphy  button,  436;  with  McGraw  rubber  suture,  437; 
gastro-enterostomy,  437;  gastro-duodenostomy,  438;  gastro- jejunostomy,  438; 
anterior  (Woelfler),  440;  suture  method,  440;  clamp  method,  443;  Jaboulay 
and  Braun  modification,  444;  posterior  gastro-jejunostomy  (von  Hacker), 
446;  without  a  loop,  446;  clamp  method,  450;  with  Murphy  button,  455;  with 
McGraw  rubber  suture,  456;  Roux,  458.— Large  Intestine  and  Vermiform 
Appendix:  Surgical  anatomy  of  the  large  Intestine,  etc.,  460;  caecum,  460; 
vermiform  appendix,  460;  ascending  colon,  462;  transverse  colon,  463; 
descending  colon,  463;  sigmoid  flexure,  463;  blood-supply  of  large  intestine, 
464.— Operations  upon  Large  Intestine:  Colostomy,  464;  left  iliac  colostomy, 
465;  right  iliac  colostomy,  470;  lateral  colostomy  without  a  spur,  470;  resec- 
tion of  caecum,  473;  end-to-end  anastomosis,  474;  lateral  anastomosis,  474; 
end-to-side,  lateral  implantation,  475;  ilio-colostomy,  475;  resection  of 
sigmoid   flexure,   476. — Operations   upon   Vermiform   Appendix:     Appendicec- 


viii  CONTENTS. 


PAGE 

tomy,  477;  McBurney  incision,  477;  Mid-rectus  incision,  478;  ligature  without 
inversion,  480;  inversion  of  stump  witii  purse-string  (Dawbarn),  481;  in- 
version (Edebohls^,  482;  for  appendicular  abscess,  482;  for  appendicitis  ac- 
companied by  general  peritoneal  infection,  486;  appendicostomy,  487. — ^Liver 
and  Gall-bladder:  Surgical  anatomy  of  the  liver,  488;  surgical  anatomy  of 
the  gall-bladder  and  bile-ducts,  490. — Operations  upon  Liver:  Hepatotomy, 
493;  for  abscess,  493;  for  hydatid  cyst,  495;  hepatectomy,  496;  injuries  to 
liver,  499;  omentopexy  (Talma),  499. — Operations  upon  Gall-bladder:  As- 
piration of  gall-bladder,  501;  cholecystotomy,  501;  cholecystostomy,  503; 
cholecystectomy,  508;  cholecyst-enterostomy,  512;  cholecysto-duodenostomy, 
512;  suture  method,  512;  clamp  method,  514;  with  Murphy  button;  chole- 
cysto-jejunostomy  suture  method,  515;  cholecysto-colostomy,  517. — Opera- 
tions upon  Gall-ducts:  Cysticotomy,  517;  hepaticotomy,  518;  choledochot- 
omy,  518;  supraduodenal  choledochotomy,  520;  retro-duodenal  choledochot- 
omy,  522;  removal  of  calculi  from  the  common  duct  through  duodenum,  523. 
—Pancreas:  Surgical  anatomy  of  pancreas,  526. — Operations  upon  Pancreas: 
Fat  necrosis,  528;  for  injuries,  529;  for  cysts,  530;  for  acute  pancreatitis,  532; 
for  tumors,  533. — Spleen:  Surgical  anatomy  of  spleen,  533. — Operations  upon 
Spleen:  Splenotomy,  534;  splenorrhaphy,  535;  splenopexy,  535;  splenectomy, 
536. — Operations  upon  Spinal  Column:  Laminectomy,  537:  lumbar  puncture, 
541. 


PAET  VI. 
The  Eectum 545-589 

Surgical  anatomy  of  the  rectum,  545;  sacrum,  545;  coccyx,  546;  rectum,  546. — 
Operations  upon  the  Anus  and  Rectum:  Dilatation  of  the  sphincter,  553; 
fistula  in  ano,  553;  for  complete  fistula,  554;  for  incomplete  fistula,  555 
hemorrhoids,  555;  ligation  and  excision,  557;  clamp  and  cautery,  559;  pro- 
lapsus recti,  559;  sigmoidopexy,  560;  resection  and  amputation  of  rectum, 
562;  perineal  method  in  continuity  (Dieffenbach),  564;  amputation  of  rec- 
tum (Lisfranc),  567;  with  preservation  of  external  sphincter,  569;  vaginal 
method,  573;  sacral  route  (Kraske),  573;  resection  of  rectum  in  continuity — 
sacral  "vor  operation,"  574;  resection  of  diseased  portion  of  rectum,  576; 
anastomosis  of  the  ends  of  the  bo-syel,  580;  amputation  of  rectum,  including 
anal  portion,  581;  combined  method  (abdomino-perineal,  abdomino-anal), 
581;  combined  operation  with  establishment  of  artificial  anus,  582;  com- 
bined operation  with  suture  of  the  end  of  sigmoid  to  anal  margin  or  anal 
portion,  586;  with  suture  of  bowel  to  anal  margin,  586;  with  anastomosis 
of   end  of  sigmoid  to  lower  anal  portion,    587. 


PART  VII. 
Hernia,  Spermatic  Cord,  Testes,  etc ■.   590-649 

Surgical  anatomy  of  groin,  590;  superficial  layer  of  superficial  fascia,  590; 
lymphatic  glands,  591;  deep  layer  of  superficial  fascia,  591;  inguinal  region, 
591;  descent  of  the  testes,  599;-  femoral  region,  604;  study  of  inguinal  and 
femoral  region  from  within  the  abdomen,  608;  inguinal  region,  608;  femoral 
region,  612.— Operations  for  Hernia:  Herniotomy,  615;  for  inguinal  hernia 
(Bassini),  618;  for  inguinal  hernia  (Halsted),  626;  for  femoral  hernia,  629; 
for  undescended  testes,  630.— Spermatic  Cord,  Scrotum,  etc.:  Spermatic 
cord,  6.34;  scrotum,  636;  testes,  636;  ejaculatory  ducts,  638.— Operations  upon 
Spermatic  Cord,  Scrotum,  etc.:  For  varicocele,  638;  for  hydrocele,  642; 
castration,  648. 


CONTENTS.  ix 

PART  VITT. 

PAGE 

ITrixary  System   650-705 

Kidneys:  Surgical  anatomy  of  kidney,  650. — Operations  upon  the  Kidney: 
Nephropexy,  655:  for  perinephritic  abscess,  659;  nephrotomy,  659;  nephro- 
lithotomy, 661;  nephrectomy,  662;  decortication  of  kidney  (Edebohls),  665. — 
Operations  upon  the  Ureter:  Ureterolithotomy,  666;  uretero-ureterostomy, 
668;  uretero-cystostomy,  669;  uretero-enterostomy,  671. — Bladder:  Surgical 
anatomy  of  bladder,  671.— Operations  upon  Bladder:  Suprapubic  cystotomy, 
674;  puncture  of  bladder,  676. — Penis:  Surgical  anatomy  of  the  penis,  677. 
— Operations  puon  the  Penis:  Forcible  dilatation  of  prepuce,  675;  dorsal 
section,  679;  circumcision,  680;  circumcision  with  clamp,  681;  amputation  of 
penis,  681. — Perineum  and  Ischio-rectal  Region:  Floor  of  pelvis  from  with- 
out, 682;  ischio-rectal  region,  683;  perineum,  684;  pelvic  cavity  from  within, 
687. — Operations  upon  Perineum,  etc.:  Perineal  section  with  a  guide,  689; 
perineal  section  without  a  guide,  690;  median  lithotomy,  690;  lateral 
lithotomy,  692. — Prostate:  Surgical  anatomy  of  prostate,  692. — Operations 
upon  Prostate:  Prostatectomy,  696;  suprapubic  prostatectomy,  696;  perineal 
prostatectomy,  698;   prostatotomy   (Bottini),  703. 


PAET  IX. 
The  Upper  Extreaiity   706-749 

The  Axilla:  The  axilla,  706;  the  axillary  artery,  706.— The  arm:  Vessels 
of  the  arm,  709;  the  brachial  artery,  709;  the  radial  artery,  712;  the  ulnar 
artery,  714;  musculo-spiral  nerve,  715;  median  nerve,  715;  ulnar  nerve,  715. 
— The  Hand:  Nerve-supply  of  the  hand,  716;  ligations,  716;  axillary,  716; 
brachial,  717;  radial,  719;  ulnar,  719. — Amputations,  Resections,  etc.:  Sur- 
gical anatomy  of  hand,  719;  phalango-phalangeal  joints,  719;  metacarpo- 
phalangeal joints,  720;  exarticulation  of  the  finger  at  the  phalango-phalan- 
geal joint,  720;  exarticulation  of  finger  at  the  metacarpo-phalangeal  joint, 
722;  exarticulation  of  hand  at  the  carpo-metacarpal  articulation,  723;  sur- 
gical anatomy  of  wrist-joint,  725;  exarticulation  of  hand  at  wrist-joint,  726; 
amputation  through  forearm,  727;  surgical  anatomy  of  elbow-joint,  728; 
exarticulation  of  forearm  at  elbow-joint,  730;  amputation  of  arm,  731;  sur- 
gical anatomy  of  shoulder-joint,  733;  exarticulation  at  shoulder-joint 
(Spence),  735;  exarticulation  at  shoulder- joint  (Esmarch),  737;  exarticula- 
tion at  shoulder-joint  with  deltoid  flap,  739. — Resections:  Wrist-joint,  742; 
elbow  (Langenbeck),  744;  shoulder,  746;  tendon  suture,  749;  nerve  suture, 
749. 

PAET  X. 
Lower  Extremity 750-825 

Thigh:  Gluteal  region,  750;  stretching  sciatic  nerve,  751;  anterior  femoral 
region,  753;  internal  saphenous  vein,  753;  femoral  artery,  754;  anterior  cru- 
ral nerve,  757;  ligation  of  femoral  artery,  757;  popliteal  space,  760. — Leg: 
Anterior  tibial  artery,  761;  anterior  tibial  nerve,  762;  posteiror  tibial  artery, 
762;  posterior  tibial  nerve,  765;  ligation  of  posterior  tibial  artery,  765; 
tenotomy,  765. — Operations  for  Varicose  Veins:  Internal  or  long  saphenous, 
766;  external  or  short  saphenous,  766;  Trendelenburg  operation,  767;  Schede's 
operation,  767;  Madelung's  operation,  769;  varicose  ulcer,  769. — Amputations, 
Resections,  etc.:  Surgical  anatomy  of  skeleton  of  foot,  770:  exarticula- 
tion of  big  toe,  772;  exarticulation  of  big  toe  with  removal  of  first  meta- 
tarsal,  772;   exarticulation   of  little  toe,   773;   for  bunion,   773;    for  hammer- 


CONTENTS. 

PAGE 

toe,  774;  for  ingrowing  toe-nail,  775;  amputation  tlirough  tarso-metartarsal 
articulation  (Lisfranc),  775;  amputation  through  medio-tarsal  articulation 
(Chopart),  778;  surgical  anatomy  of  ankle-joint,  779;  exarticulation  of  foot 
at  ankle-joint  (Syme),  780;  exarticulation  of  foot,  etc.  (Pirogoff),  782; 
amputation  of  leg,  784;  amputation  of  leg  with  lateral  hooded  flaps,  784; 
surgical  anatomy  of  knee-joint,  787;  exarticulation  of  leg  at  knee-joint 
(Stephen  Smith),  790;  transcondylar  amputation  (Garden),  792;  amputation 
of  knee  (Gritti-Stokes),  794;  amputation  of  thigh,  795;  surgical  anatomy  of 
hip- joint,  797;  exarticulation  of  thigh  at  hip  (Wyeth),  800;  exarticulation 
of  thigh  with  preliminary  ligation  of  common  femoral,  803. — Resections: 
Ankle  (Langenbeck-Hueter),  803;  ankle  (Koenig),  807;  ankle  (Lauenstein), 
809;  ankle,  osteoplastic  (Mikulicz-Wladimirow),  810;  knee-joint,  812;  hip- 
joint  (Langenbeck),  817;  plating  for  fracture  (Lane),  821;  of  patella,  822; 
osteotomy,  824. 


LIST  OF  ILLUSTRATIONS. 


FIG.  PAGE 

1.  Gwathmey's   Three-bottle  Apparatus,    Mask   and   Tube    6 

2.  Lumbard's  Nasal  Tubes   7 

3.  Mouth-gag  with  Perforated  Tubes  along  Blades   8 

4.  Junker   Chloroform  Apparatus    9 

5.  Division  of  the  Skin   by   Transfixion    16 

6.  Esmarch    Bandage    and    Constrictor    18 

7.  Trendelenburg  Position    20 

8.  Square  Knot   23 

9.  Slip   Knot    ■ - ,..  23 

10.  Surgeon's  Knot   23 

11.  Superficial  Vein  Exposed  for  Saline  Infusion  25 

12.  Arterio-venous   Transfusion 26 

13.  Arterio-venous    Anastomosis,    Suture    Method    28 

14.  Crile's   Cannulas    29 

15.  16,  17,  18.    Arterio-venous  Anastomosis   with   Crile's   Cannula,   etc 29,  30,  31 

19.  Brewer's  Transfusion   Tubes   32 

20.  Intracuticular   Suture    34 

21.  Suture  of  Tendon    35 

22.  Bone  Drill  with  Eye  Near  the  Point  to  Carry  Suture,  etc 36 

23,24.     Segment   of   Bowel— Lembert   Sutures    36 

25.  Cushing    Suture    37 

26.  Halsted's    Intestinal    Suture    37 

27.  Non-penetrating    Suture    38 

28.  Side  of  Skull '.  43 

29.  Transverse  Section  through  the  Anterior  Fossa   45 

.30.    Base  of  the  Skull  from  Within   47 

31.  Middle  Fossa  showing  the  Position  of  the  Gasserian  Ganglion' 50 

32.  Cross-section  through  Middle  Fossa  Just  Anterior  to  the  Position  of  Gasserian 

Ganglion     51 

33.  Schema  showing  Parts  Derived  from  the  Three  Original  Brain  Vesicles  57 

34.  External  Surface  of  the  Cerebrum   58 

35.  Surface  of  Cerebrum  from  above   59 

36.  Showing   the   Motor   Area,    etc 60 

37.  Internal   Surface  of  the  Cerebrum    61 

38.  Under  Surface  of  the   Cerebrum   62 

39.  Section  through   Scalp,   Skull,   Brain,   etc 63 

40.  Chiene's  Schema  to  Locate  the  Fissure  of  Rolando,  etc 65 

41.  Rolandic   Angle   66 

42.  Kronlein's  Schema,  to  Locate  the  Fissure  of  Rolando,  etc 67 

43.  Kocher    Craniometer    68 

44.  Various  Fissures,   etc.,   Indicated  by  Kocher  Craniometer   69 

45.  Doyen  Perforator  and  Burr 70 

46.  Hudson's    Trephining   Instruments    71 

47.  Depressed  Fracture  of  the  Skull    73 

48.  Hartley    Chisel    74 

49.  50.     Temporary  Resection  of  the  Skull   75,  76 

51.  Hudson-De   Vilbiss   Bone-forceps    77 

52.  Incision  for  Temporal  Decompression   80 

53.  Decompressive  Operation  in  Temporal  Region   (Cushing)   81 

54.  Location   of  Various   Skull   Flaps    (Mills)    83 

55.  Kredel's  Blocks  in  Position   85 

(Xi) 


xii  LIST  OF  ILLrSTRATIOXS. 

FIG.  PAGE 

56,  57.    Formation  of  the  Osteo-tegumentary  Flap   (Marion)   86,  87 

58.  Marlon  Separator  and  Conductor  88 

59.  Formation  of  the  Osteo-tegumentary  Flap  (Marion)  89 

60.  Doyen    Guarded    Chisel    90 

61.  Exposure    of    Cerebellum    93 

62.  Gushing   Cross-bow   Incision    94 

63.  Exposure  of  One-half  of  the  Cerebellum   (Erause)    95 

64.  Drainage  of  the  Lateral  Ventricle  99 

65.  Frontal   Sinus   103 

66.  Hartley-Krause    Operation    107 

67.  Zygomatic  Arch   Resected   (CusJiing)    109 

68.  Resection   of  the   Gasserian   Ganglion,    etc Ill 

69.  Side  of  Skull    115 

70.  Right  Membrana  Tympani  Viewed  through  the  Auditory  Canal  117 

71.  Section  through  the  Right   Temporal   Bone    119 

72.  Simple  Mastoid  Operation   125 

73.  74.    Pterygo-maxillary     Region     139,  141 

75,76.    Resection   of   Upper   jaw    , 144,145 

77.  Incision  for  Resection  of  the  Temporo-maxillary  Joint  155 

78.  Points  of  Injection  of  the  Superior  and  Inferior  Maxillary  Branches   159 

79.  Transverse  Section  of  the  Head  End  of  an  Embryo  Twelve  Days  Old  162 

80.  Sagittal  Section  of  the  Head  End  of  an  Embryo  Twelve  Days  Old   IBS 

81.  82.    Face  of  Embryo,   Fifth  TS'eek   164,  165 

83.  Embryo  about  Fourth  Week,   seen  from  Side  166 

84.  Embryo    about   Eighth    Week    167 

85.  Face   of   Embryo   about  Eighth   Week    169 

86.  Diagram  of  Congenital  Facial  Clefts   171 

87.  Double    Complete    Harelip    173 

88.  Harelip   with   Advanced   Intermaxillary   Portion    174 

89.  Double  Cleft  Palate  with  Advanced  Intermaxillary  Portion  Carrying  Sockets  of 

Two   Incisor   Teeth    175 

90.  Oblique  Facial   Cleft  Extending  into  the  Temporo-frontal  Region   176 

91.  Incomplete    Oblique    Facial    Cleft    177 

92.  Transverse   Facial    Cleft   178 

93.  Simple  Paring  of  the  Edges   of  the  Notch  for  Incomplete  Harelip    180 

94.  Imperfect  Result  After  Simple  Paring  and   Suture 180 

95.  96.    Von   Graele  Method   of  Paring  an  Incomplete  Harelip    181 

97,98,99.    Nelaton    Operation   for  Incomplete   Harelip    181,182 

100,  101,  102.     Malgaigne  Operation  for  Incomplete  Harelip   182 

103,  104,  105.    Mlrault   Operation   for   Incomplete   Harelip    183 

106.  Wellenschnitt   for    Complete   Harelip    184 

107,  108,  109.    Hagedorn    Operation  for   Single   Complete  Harelip    184,  185 

110,  111,  112.     Double   Mlrault   Operation   for   a   Double    Complete  Harelip    186 

113,  114,  115.    Hagedorn   Operation  for  Complete   Double   Harelip    187 

U6.    Whitehead    Gag    189 

117.  Repair   of    Cleft    Palate    191 

118.  Strips  of  Gauze  Passed  around  the  Flaps   193 

119.  Brophy's  Needle  for  Passing  Sutures   194 

120.  121.  ^Brophy's    Operation    195 

122.  Excision   of  Entire   Lower   Lip    Ifi7 

123.  Triangular  Defect  in   Lower  Lip    Closed   by   Suture    197 

124.  Dieffenbach- Jaesche  Operation  for  Restoring  Lower  Lip    189 

125.  126.  Bruns   Method  of   Restoring   Lower   Lip    1S8 

127,  128.  Langenbeck  Method  of  Restoring   Lower  Lip    199 

129,  130.  Estlaender's  Method  of  Restoring  Lower  Lip    199 

131,  132.  Dieffenbach  Wellenschnitt  for  Restoration  of  Upper  Lip    200 

133,  134.  Bruns   Method    of   Restoring   Upper   Lip    200 

135.  Section  through  Neck  203 

136.  Side  of  Xeek  to  Show  Triangles  207 


LIST  OF  ILLUSTRATIONS.  xiii 

FIG.  PA°E 

137.  Front   of    Neck    215 

138.  Incision   for  Removal  of  Lower  Jaw,   etc 231 

139.  Fascio-hypoglossal    Anastomosis    iFra~ier)    237 

140.  Incisions  for  Gaining  Access  to  Various  Triangles  of  Neck  243 

141.  Tracheotomy    Tube    245 

142.  Trendelenburg    Tampon    Cannula    245 

143.  Thyroidectomy    2.59 

144.  Transverse  Section   Through   Thorax    283 

145.  Outline   of  Heart,    etc 286 

146.  147,  148.     Outline   of   Pleura,    etc    295,  297 

149.  Section  Through  Seventh,  Eighth,  and  Ninth  Ribs   298 

150.  Amputation    of   Breast    303 

151.  Posterior  Aspect  of  Sternum  and  Ribs   312 

152.  Incision  in  Soft  Parts  for  Exposure  of  Heart  31S 

153.  154.     Transverse  Section  of  Abdomen  327 

155.  Regions  of  Abdomen   331 

156,  157,  158.    Umbilical    Hernia    350,  351 

159.  Sagittal  Section  to  Show  Arrangement  of  Greater  and  Lesser  Omenta  357 

160.  Stomach,    Showing  Arteries,    Lymphatics,   etc.    (colored)    359 

161.  Various   Abdominal    Incisions    361 

162.  Plication  of  Gastro-hepatic  Ligament  (Beyea)   362 

163,104.     Cross   Section  of  Stomach   After  Gastroplication    363 

165.  Posterior  Wall  of  Stomach  Pushed  out  Through  Incision  in  Anterior  Wall  367 

166,  167.     Pyloroplasty 370 

168,  169,  170,  171.     Pyloroplasty   {Finney)    371,  373 

172,  173.    Gastrostomy   (Ssahanajew-Franck)    377 

174,  175.     Gastrostomy   (Witzel)    378 

176.  Gastro-gastrostomy   383 

177.  Pylorectomy     386 

178.  Pylorectomy    (Billroth)    387 

179.  Restoration   of   the  Gastro-intestinal    Canal    (Billroth)    389 

180.  Pylorectomy    (Kocher)    392 

181.  Doyen   Holding   Forceps    393 

182.  Hartmann    Holding     Forceps 393 

183.  Gastrectomy    (Hartmann)    395 

184.  185,  186.    Gastrectomy    (Mayo)    397,  401,  402 

187.  Gastrectomy 404 

188.  Section  of  Intestine,   etc.,   "Dead  Space"    409 

189.  Blood-supply  of  Small  Intestine   409 

190.  Enterostomy    412 

191.  Jejunostomy    (Maydl)    415 

192.  Enterectomy  421 

193.  194,  195,  196,  197.    End-to-End  Anastomosis    (McOrath)    424,  425,  426,  427 

198,  199,  200.     End-to-End  Anastomosis    (Mounsell)    428,  429 

201.  End-to-End   Anastomosis  with   Murphy   Button    432 

202.  Lateral   Anastomosis    435 

203.  Lateral  Anastomosis  with  Murphy  Button   435 

204.  Gastro-duodenostomy    (Kocher)    439 

205.  Anterior  Gastro-jejunostomy    (Suture   Method)    441 

206.  Jaboulay   and  Braun   Modification    445 

207.  Posterior    Gastro-jejunostomy    447 

208.  Posterior  Gastro-jejunostomy  Without  a  Loop  (Czerny)    449 

209.  Posterior   Gastro-jejunostomy    450 

210,211.     Gastro-jejunostomy,   (Clamp  Method)    451 

212.  Posterior  Gastro-jejunostomy  (Mayo)    452 

213,  214.    Gastro-jejunostomy    (Clamp   Method)    453 

215.  Gastro-jejunostomy    (McGrau)    457 

216.  Posterior   Gastro-jejunostomy    (Roux)    459 

217.  218,  219.    Colostomy   467,  469 


xiv  LIST  OF  ILLUSTRATIONS. 

FIG.  PAGE 

220.  Paul's    Tube    470 

221,  222,  223.     Colostomy 471,  472 

224,  225,  226.    Appendiceetomy  479,  480,  481 

227.  Bile    Ducts,    etc 492 

228.  Kousnetzofl   and    Pensky    Suture    497 

229.  230.    Control  of  Hemorrliage  from  Liver   {Payr  &  Martina) 498 

231.  Ligature  Carrier  and  Needle  {Payr  &  Martina)   498 

232.  Control  of  Hemorrhage  from  Liver    499 

233.  234.     Cholecystostomy    505 

235.  Cholecystectomy    509 

236.  Cholecysto-duodenostomy   with   Murphy   Button    514 

237.  Choledochotomy    .' 519 

238.  Method  of  Suturing  Incision  in  Common  Duct   521 

239.  Lower  Part  of  Common   Duct   524 

240.  Pancreatic   Duct   526 

241.  Laminectomy  539 

242.  Lumbar  Puncture  543 

243.  The  Rectum 547 

244.  Complete  Fistula  in  Ano   553 

245.  Blind  Internal  Fistula   .  / 554 

246.  Blind   External   Fistula    555 

247.  248.    Operation   for  Hemorrhoids   556,  557 

249.  Rectal  Tube  Wrapped  with  Gauze  558 

250.  Sigmoidopexy 561 

251.  Resection  of  Rectum  {Quenu)    569 

252.  253,  254,  255.    Amputation  of  Rectum   (Quenu)    570,  571,  572,  573 

256.  Resection  of  Rectum  (KrasJce)  574 

257.  Back  Part  of  Ilium  and  Sacrum  575 

258.  259,  250.    Resection  of  Rectum  (Kraske)   577,  578,  579 

261.     Blood-supply  of  Sigmoid  Flexure  and  Rectum   583 

262,263,264.    Resection   of   Rectum    (Abdomino-anal   Method)    587,588 

265.  Inguinal  and  Femoral  Regions   593 

266.  The  Inguinal   Canal   595 

267.  Descent  of   Testis    (colored)    601 

268.  Normal  Condition  of  Inguinal  Region,   Scrotum,   etc.    (colored)   603 

269.  Condition    of    Parts   in    Presence   of   a   Congenital    (Oblique   Inguinal)    Hernia 

(colored)   603 

270.  Condition    of    Parts    in    Presence    of    an    Acquired    Oblique    Inguinal    Hernia 

(colored)   603 

271.  Superficial   Femoral   Region   607 

272.  Superficial  Femoral  Region— Femoral   Sheath   607 

273.  The  Pelvis  and  Ligaments  of  Ilio-pubic  Regions   609 

274.  Femoral    Space    609 

275.  Deep   Femoral   Region    611 

276.  Inguinal  and  Femoral  Regions  from  Within  Abdomen  613 

277.  Irregular  Origin  of  Obturator  Artery   616 

278.  Irregular  Origin  of  Obturator  Artery   617 

279.  Operation   for  Inguinal   Hernia    619 

280.  Bassini   Operation   for  Inguinal   Hernia   621 

281.  Bassini   Operation    623 

282.  Halsted's  Operation   628 

283.  Operation  for  Femoral  Hernia   631 

284,285,286,287.    For    Undescended    Testis    633,635 

288.  Spermatic  Cord 637 

289.  Cross  Section  of  Spermatic  Cord  637 

290.  Exposure  of  Spermatic  Cord  639 

291.  292.    Varicocele  640,  641 

293.  Hydrocele,    Tapping    643 

294.  Volkmann  Operation  for  Hydrocele  .-. .-..  645 


LIST  OF  ILLUSTRATIONS.  XV 

FIG.  PAGE 

295.  Hydrocele    646 

296.  Castration    647 

297.  Right  Kidney  from  Behind  651 

298.  Incision  for  Exposure  of  Kidney   655 

299.  Lumbar  Incision  for  Exposing  Kidney   656 

300.  Nephropexy 657 

301.  Uretero-ureterostomy   (Van  Hook)    668 

302.  Uretero-ureterostomy   (Bovee)    669 

303.  304.    Uretero-cystostomy    670,  671 

305.  An  Antero-posterior  Section  Showing  Relations  of  Peritoneum  to  Bladder,  etc. . .  673 

306.  Dorsal   Section    (Roser)    678 

307.  Circumcision    679 

308.  309.    Amputation   of   Penis    681,  682 

310.  Perineum  and  Ischio-rectal  Region   685 

311.  Transverse  Section  of  Prostate 694 

312.  Suprapubic   Prostatectomy   697 

313.  Incision   for   Perineal   Prostatectomy    699 

314.  Young's  Tractor,   Closed   700 

315.  Young's  Tractor,  Open   700 

316.  Perineal  Prostatectomy   (Young)    701 

317.  Enucleation  of  Middle  Lobe  702 

318.  Axillary    Region    707 

319.  Section  Through  Middle  of  Right  Arm  711 

320.  Section   Through  Middle  of  Right  Forearm   713 

321.  Right  Arm   718 

322.  Exarticulation  of  Finger  at  Phalango-phalangeal  Joint   721 

323.  Exarticulation  of  Finger  722 

324.  Palmar  Aspect  of  Right  Hand   724 

325.  Dorsal  Aspect  of  Right  Hand   724 

326.  Stump  Result  of  Exarticulation  of  Hand  at  Carpo-metacarpal  Joint  725 

327.  Right  Arm,  Anterior  Aspect  , 732 

328.  Right  Shoulder,   Anterior  View   736 

329.  Right  Shoulder,   Posterior  View    738 

330.  Left  Shoulder,  Side  View   739 

331.  Left  Arm,   Posterior  View   741 

332.  Resection  of  Wrist-joint  742 

333.  Stretching   Sciatic   Nerve    752 

334.  Section  Through  Middle  of  Right  Thigh   755 

335.  Ligation  of  Femoral  Artery   758 

336.  Section  Through  Middle  of  Right  Leg  763 

337.  338.     Operation   for  Varicose  Veins   768 

339.  Right  Foot,  Articulation  and  Amputation  770 

340.  Osteotomy  for  Bunion   773 

341.  Operations  for  Ingrowing  Toe-nail   775 

342.  Right   Foot,    Inner    Side 777 

343.  Right   Foot,    Outer   Side   777 

344.  345,  346.     Right  Foot,   Inner  Side  781 

347.  Amputation   of   Leg    785 

348.  Right  Leg,    Outer   Side   791 

349.  Right    Leg    (Garden's    Amputation)    793 

350.  Stump  After  Garden's  Amputation    793 

351.  Gritti-Stokes  Amputation   795 

352.  Exarticulation  at  Hip- Joint   801 

353.  Right  Foot,   Outer   Side   (Langenbeck-Hueter)    804 

354.  Right  Foot,  Inner  Side  (Langenbeck-Hueter)   804 

355.  Incisions  for  Resection  of  Ankle  (Koenig)  and  for  Amputation  of  Big  Toe  with 

Removal  of  First  Metatarsal   807 

356.  Resection  of  Ankle-joint   (Lauenstein's  Incision)    810 

357.  Right  Foot,    Inner   Side    811 


xvi  LIST  OF  ILLUSTRATIONS. 

FIG.  PAGE 

35s.     Right   Leg,    Inner   Side    813 

359.  Resection   of   Knee-joint    815 

360.  Resection  of  Hip  (Langenbeck's  Incision)   818 

361.  Resection  of  Hip  (Anthony  White's  Incision)    819 

362.  Plating   for   Fracture    (Lane) 821 

363.  Operation   for   Fracture   of   Patella   823 

364.  Osteotomy    (Macewen)     824 


PART   I. 

GENERAL  CONSIDERATIONS. 


AN/ESTHESIA. 

General  Anassthesia. — Of  the  general  anaesthetics  ether  and 
chloroform  are  the  most  commonly  emplo3'ecI.  Xitrous  oxide  and 
ethyl  chloride  are  only  used  for  short  operations  or  preliminary  to 
the  administration  of  ether  in  order  to  avoid  the  excitement  and 
struggling  of  the  first  stage.  Of  the  two  anaesthetics,  ether  and  chloro- 
form, the  former  is  employed  more  commonly  than  the  latter  in  the 
United  States. 

Ethee  is  unquestionahly  a  safer  anaesthetic  than  chloroform, 
and  is  to  l)e  employed  in  all  cases  except  where,  for  some  special 
reason,  its  use  is  eounterindicated.  Ether  stimulates  the  heart  and 
increases  the  arterial  tension.  It  counteracts  the  tendency  to  shock. 
It  has  a  marked  congestive  influence  upon  the  kidneys  and  acts  as 
an  irritant  to  the  respiratory  tract.  Ether  is  therefore  eounterin- 
dicated in  cases  of  marked  atheroma,  and  in  aneurism  of  the  thoracic 
and  abdominal  aorta.  In  renal  disease  it  is  to  be  used  sparingly 
and  cautiously  if  at  all.  Bronchitis  and  broncho-pneumonia  occur 
more  frequently  after  ether  than  after  chloroform,  but  some  of  these 
cases  are  due  to  exposure,  dirty  inhalers,  and  are  avoidal)le. 

Chloroform  is  a  very  dangerous  drug  and  requires  much  ex- 
perience and  care  in  its  administration.  Statistics  show  ten  fatalities 
with  chloroform  to  one  with  ether.  Chloroform  is  less  dangerous 
when  used  in  hot  climates  and  high  altitudes  than  in  cool  climates 
and  lower  altitudes.  The  first  stage  of  chloroform  narcosis  is  shorter 
than  is  that  of  ether  and  is  not  accompanied  by  as  much  excitement 
and  struggling.  Chlorofonn  does  not  irritate  the  kidneys  to  the  same 
degree  that  ether  does.  Chloroform  has  a  peculiar  depressing  in- 
fluence upon  the  heart  action  and  lowers  the  blood-pressure.  If  the 
heart  muscle  is  diseased,  as  in  cases  of  myocarditis,  fatty  heart,  and 
in  conditions  accompanied  by  chronic  an?emia,  chloroform  may  cause 
sudden  death.  Ether  is  unquestionably  the  preferable  ana?sthetic,  and 
is  to  be  used  as  the  routine  anaesthetic  in  practically  all  cases,  reserv- 

1  (1) 


2  GENERAL  COiNSIDERATIONS. 

ing  ehlorofomi  for  the  exceptional  cases  and  for  nse  in  small  quan- 
tities during  the  course  of  ether  anaesthesia  to  overcome  occasional 
resistance,  muscular  spasm,  etc.  Chloroform  anesthesia  may  be  em- 
ployed if  the  urine  shows  defective  kidneys,  although  in  advanced 
kidney  disease  chloroform  is  counterindicated  on  account  of  its  de- 
structive effect  upon  the  secreting  cells  of  the  kidneys.  Chloroform 
may  be  used  where  there  is  a  tendency  to  cerebral  apoplex}^  or 
pulmouan'  disease  and  in  cases  of  empyema.  Alcoholics  and  athletic 
persons  take  chloroform  much  more  easily  than  ether.  In  these  peo- 
23le,  when  ether  anaesthesia  is  employed,  it  is  of  great  advantage  to 
occasionally  add  small  cjuantities  of  chloroform  during  the  course 
of  the  anaBsthetization.  Chlorofonii  is  well  borne  during  labor,  but 
should  not  be  used  in  cases  of  threatened  eclampsia  on  account 
of  its  destructive  effect  upon  the  cells  of  the  liver  and  kidneys. 
Chloroform  is  not  to  be  used  in  diabetics.  In  operations  upon  the 
brain  and  spinal  cord  chloroform  is  preferred  by  some  operators,  as 
the  hemorrhage  is  said  to  be  less  than  when  ether  is  employed.  In 
operations  about  the  mouth  and  upon  the  respiratory  passages  where 
the  mask  can  only  be  applied  at  intervals  and  for  administration 
through  a  tracheotomy  tube  chloroform  is  the  preferable  aneesthetic. 
Chloroform  is  uot  a  safe  anesthetic  in  tonsil  and  adenoid  operations. 

Mixtures  of  chloroform  and  ether  or  of  alcohol,  chloroform,  and 
ether  have  been  employed  extensively  by  some  surgeons,  especially 
in  England,  but  they  have  never  come  into  very  general  use  in 
America.  In  the  chloroform  and  ether  mixture  the  proportions  are 
2  of  chloroform  and  3  of  ether.  The  proportions  of  the  "A.  C.  E." 
mixture  are  1  of  alcohol,  2  of  chloroform,  and  3  of  ether.  The 
mixture  should  be  made  immediately  before  using  and  should  be 
considered  as  chloroform.  A  very  satisfactory  method  of  combining 
ether  and  chloroform  is  to  administer  ether  by  the  drop  method 
with  the  occasional  addition  of  a  few  drops  of  cliloroform.  This 
plan  gives  a  very  satisfactory^  anesthesia  in  young  children  and  in 
the  aged.  The  admixture  of  ether  and  chloroform  vapors  may  be 
obtained  in  any  desired  proportion  with  the  Gwathmey  apparatus. 

AcETOXiEMiA. — Ether  and  chloroform  may  both  produce  acetone- 
mia. Following  the  administration  of  ether,  this  condition  is  less 
serious  than  after  chloroform  because  ether  causes  less  damage  to 
the  cells  of  the  liver  and  kidneys  and  does  not  interfere  with  the 
prompt  elimination  of  the  poison.  After  the  administration  of  chloro- 
form, especially  if  prolonged,  and  also  in  rare  cases,  after  the  ad- 


ANAESTHESIA.  3 

iiiinistration  of  etlicr,  there  may  ocfiTr  a  form  of  poisoning  charac- 
terized by  acetonfemia  and  fatty  degeneration  of  the  liver,  kidneys, 
heart,  and  muscular  structures.  The  changes  in  the  liver  resemble 
acute  yellow  atrophy.  Symptoms  usually  appear  within  forty-eight 
hours  after  the  anaesthetic  has  been  administered.  They  may  appear 
within  fifteen  hours  or  they  may  be  delayed  for  five  or  six  days. 
The  SAaiiptoms  are  a  greater  or  less  degree  of  jaundice,  persistent 
vomiting — the  vomited  matter  finally  resembles  the  dregs  of  beef-tea — - 
restlessness,  delirium,  stupor,  the  patient  gradually  passing  into  a  con- 
dition of  coma;  respiration  embarrassed,  maybe  Cheyne-Stokes  in 
character ;  skin  cyanotic.  The  breath  has  a  pronounced  odor  of  acetone 
and  the  urine  contains  albumin,  casts,  and  acetone,  and  diacetic  and 
betaoxybutyric  acids.  The  termination  is  usually  fatal.  This  con- 
dition is  more  likely  to  occur  in  the  young;  the  debilitated,  starved, 
anaemic;  those  suffering  from  suppurative  conditions;  those  with  dis- 
eased liver,  kidneys,  diabetics.  It  may  occur  in  those  who  were  ap- 
parently healthy  before  the  administration  of  the  chloroform.  That 
this  condition  may  occur  as  the  result  of  the  administration  of  chloro- 
form is  another  reason  why  this  drug  should  be  avoided,  especially 
for  prolonged  operations. 

Nitrous  Oxide,  Laughing  Gas. — When  pure,  this  agent  is  en- 
tirely free  from  irritant  properties.  It  is  supplied  for  anaesthetic 
administration  in  liquid  fonn  in  iron  cj'linders. 

Nitrous  oxide  may  be  employed  as  the  anesthetic  with  much 
satisfaction  for  short  surgical  operations,  and  also  to  induce  the  first 
stage  of  angesthesia  preliminary  to  the  use  of  ether.  In  this  wav  the 
struggling  and  muscular  spasm,  etc.,  of  the  primary  stage  of  ether 
angesthesia  are  avoided.  If  nitrous  oxide  is  employed  as  the  anaesthetic 
for  brief  surgical  operations  or  preliminary  to  ether  administration 
it  may  be  used  pure.  Under  these  circumstances  a  very  brief  period, 
from  one-half  to  two  minutes,  is  required  to  induce  ana?sthesia. 

For  surgical  procedures  of  longer  duration  the  administration 
of  the  nitrous  oxide  must  be  interrupted  with  occasional  inspirations 
of  air  or  else  the  gas  must  be  diluted.  It  may  be  administered  pure, 
allowing  occasional  inspirations  of  air, — everv'  second  or  third  in- 
spiration,— or  else  the  slide  in  the  tube  attached  to  the  mouth-piece 
may  be  kept  partially  open  all  the  time,  thus  permitting  continuous 
entrance  of  the  atmospheric  air  and  admixture  with  the  nitrous  oxide. 
In  this  manner  anesthesia  with  nitrous  oxide  may  be  continued  for 
from  five  to  ten  minutes.     During  the  nitrous-oxide  anaesthesia  the 


4  GENERAL  CONSIDERATIONS. 

respiration  should  be  regular  and  snoring  and  accompanied  with  on'y 
a  moderate  degTee  of  duskiness.  ISTitrons  oxide  is  to  be  avoided  in 
pregnancy.  If  used  it  should  not  be  pushed,  as  it  is  desirable  to 
avoid  marked  clonic  spasms  which  occur  during  the  course  of  nitrous 
oxide  administration.  Xitrous  oxide  is  counterindicated  in  myocar- 
ditis, degeneration  of  the  heart  muscle,  fatty  heart,  and  in  thick-necked, 
asthmatic  persons,  and  in- empyema. 

The  mixture  of  nitrous  oxide  and  oxygen  is  the  safest  of  all 
angesthetics,  and  may  be  used  for  jorolonged  surgical  operations  in 
many  cases  where  both  ether  and  chloroform  would  be  dangerous. 
The  condition  of  anaesthesia  will  be  made  much  more  even  and  sat- 
isfactory^ for  operative  purposes  and  without  adding  materially  to 
the  danger  by  the  addition  of  small  quantities  of  ether  or  chloro- 
form to  the  mixture  of  gases.  This  is  accomplished  by  forcing  the 
gases  through  a  bottle  containing  the  ether  or  chloroform.  The  ad- 
ministration of  this  mixture  requires  special  apparatus  and  special 
skill  and  experience  upon  the  part  of  the  anaesthetist. 

Ethyl  Chloeide,  a  colorless,  very  volatile  liquid,  peculiar  pen- 
etrating odor,  very  combustible.  It  is  supplied  in  tubes  or  in  cap- 
sules containing  3  to  5  c.c.  The  smaller  dose  is  sufficient  for  inducing 
anaesthesia  in  children,  the  larger  for  adults.  Anaesthesia  is  obtained 
in  about  ninety  seconds  and  lasts  about  one  minute  and  a  half. 
Ethyl  chloride  is  usually  administered  in  a  closed  inhaler,  but 
anaesthesia  may  also  be  obtained  by  throwing  a  continuous  spray  of 
ethyl  chloride  ujjon  a  Schimmelbusch  mask.  Eather  wasteful  of  the 
drug,  but  quite  satisfactory  method  of  inducing  anaesthesia.  Ethyl 
chloride  is  a  very  satisfactory  and  safe  anaesthetic  for  children  and 
for  short  operations.  It  is  used  instead  of  nitrous  oxide  preliminary 
to  ether  in  children  for  inducing  the  first  stage  of  anaesthesia.  The 
breathing  is  regular,  deep,  becoming  stertorous;  there  is  loss  of  con- 
junctiva reflex;  the  pupils  become  dilated;  the  face  is  not  livid,  and 
there  is  no  muscular  spasm. 

Incomplete  General  Anaesthesia. — This  plan  consists  in  admin- 
istering a  liberal  dose  of  moi*phin  hj'podermically,  one-half  hour 
before  commencing  the  operation,  and  then  giving  the  chloroform  up 
to  the  point  of  deadening  the  sensation  without  nullifying  the  re- 
flexes. In  this  way  the  pain  is  made  endurable  and  at  the  same 
time,  the  reflexes  being  still  active,  the  patient  is  able  to  cough,  clear 
the  throat,  and  expectorate.  This  plan  of  anaesthesia  may  be  prac- 
ticed with  satisfaction  in  operations  about  the  upper  and  lower  jaw. 


AJM^STHESIA.  T) 

nasal  passages,  larynx,  etc.,  where  there  is  danger  of  1)lo()(l  entering 
the  respiratory  canal  and  asphyxiating  the  patient  if  not  coughed  out. 

The  Administration  of  Anaesthetics  has  become  much  more  com- 
plicated in  recent  years,  owing  to  improved,  but  complicated,  ap- 
paratus, and  to  the  practice  of  combining  .different  ansesthetics  with 
each  other  and  with  air  and  oxygen.  It  is  very  desirable  that  the 
routine  administration  of  anesthetics  be  entrusted  to  an  experienced 
ana?sthetist  wherever  this  is  possible,  and  this  becomes  particularly 
necessary  in  unusual  and  dangerous  cases. 

The  choice  of  the  anesthetic  will  vary  according  to  the  nature 
of  the  operation,  condition,  and  age  of  the  patient. 

Ether. — This  anesthetic  may  be  given  by  the  open  or  closed 
method,  or  by  the  vapor  method. 

Open  Metliod. — A  very  common  plan  is  to  administer  the  ether 
drop  by  drop  upon  a  SchimmenDusch  mask,  which  is  covered  with 
several  layers  of  gauze.  This  is  commonly  called  the  "drop  method,'' 
is  a  very  safe  and  simple  way  of  administering  ether,  and  is  a  fa- 
vorite method  with  those  who  are  not  familiar  with  the  more  com- 
plicated inhalers.  This  method  is  very  satisfactory  for  children.  A 
few  drops  of  chloroform  may  be  poured  upon  the  mask  occasionally 
during  the  course  of  the  anesthesia  or  in  the  beginning  of  the 
anesthesia  if  conditions  warrant  the  addition  of  this  drug.  The 
Allis  inhaler,  or  the  old-fashioned  folded-towel  cone,  may  be  used  to 
administer  ether  by  the  open  method.  .  The  end  of  the  Allis  inhaler, 
or  folded-towel  cone,  may  be  stuffed  so  tight  with  cotton  or  gauze 
as  to  give  the  patient  a  very  large  percentage  of  ether. 

Closed  Metliod. — Also  called  the  rebreathing  method.  This  con- 
sists of  breathing  and  rebreathing  the  same  air  charged  with  ether 
vapor  in  and  out  of  a  bag.  A  Bennett  inhaler,  or  some  one  of  its 
modifications,  is  employed.  A  great  advantage  of  this  method  is  that 
much  less  ether  is  used  and  the  patient  is  therefore  much  less  satu- 
rated with  the  drug.  It  requires  less  ether  to  induce  anesthesia  and 
much  less  to  keep  the  patient  under  during  the  course  of  the  opera- 
tion. This  plan  requires  familiarity  "^vith  the  apparatus  upon  the 
part  of  the  administrator. 

YapoT  Metliod. — After  anesthesia  has  been  induced  one  may 
continue  to  administer  the  ether  through  a  Junker  bottle  or,  better, 
through  the  apparatus  of  Gwathmey,  which  permits  of  the  admixture 
of  chloroform  to  the  ether  in  any  proportion  as  may  be  indicated 
during  the  course  of  the  operation. 


6 


GENERAL  CONSIDERATIONS. 


The  Gwathme}^  apparatus  consists  of  three  bottles.  One  bottle 
contains  ether,  another  chloroform,  and  the  third  water.  Air  is 
forced  throngh  the  fluids  in  the  bottles  by  means  of  a  nibber  bulb 
that  may  be  worked  either  by  hand  or  by  foot  pressure.  The  ap- 
paratus is  provided  Avith  a  cock  which  may  be  arranged  so  as  to  direct 
all  the  air  through  the  bottle  containing  ether,  or  through  the  bottle 
containing  chloroform,  or  through  both  bottles  at  the  same  time  in 
any  desired  proportion.  Thus,  if  the  stop-cock  indicates  air  the  pa- 
tient is  getting  no  anaesthetic  whatever,  nothing  but  unaltered  atmos- 


Fig.  1.— .4,  Gwathmey's  three-bottle  apparatus;  B,  mask  with  perforated  rim; 
C,  tube  for  administering  anesthetic  in  mouth  operations,  etc. 

pheric  air;  if  the  cock  indicates  ether  he  is  getting  all  the  ether 
vapor  that  the  current  of  air  passing  through  the  ether  bottle  can 
take  up;  if  the  indicator  points  to  chloroform  he  is  getting  chloro- 
form; if  the  indicator  is  placed  half-way  between  ether  and  chloro- 
form he  is  getting  equal  parts  of  both  drugs.  The  proportions  may 
be  changed  as  desired  by  moving:  the  indicator.  With  this  apparatus 
a  safe  and  very  satisfactory  state  of  angesthesia  may  be  maintained. 
The  mask  which  is  used  is  shaped  like  the  Schimmelbusch,  but  the 
rim  is  hollow  and  is  perforated  by  a  number  of  little  holes.  The 
vaporized  ether  or  chloroform,  or  mixture  of  both,  is  forced  through 
the  little  perfoi'ations  in  the  rim  of  the  mask.  In  operations  upon 
the  mouth,  etc.,  the  vapor  may  be  discharged  in  the  back  of  the  mouth 
by  using  the  bent  tube  shown  in  Fig.  1. 


ANAESTHESIA. 


It  is  desirable  that  the  vapor  be  warmed,  and  this  is  accomplished 
by  interposing  a  heater  between  the  bottles  containing  the  ether, 
chloroform,  and  the  mask.  This  heater  contains  thermolite  salts. 
It  is  placed  in  very  hot  water  and  thus  heated.  It  will  remain  hot 
for  one  or  two  hours.  The  ether  and  chloroform  vapor  passes  through 
the  heater  before  reaching  the  mask  and  is  thus  warm  when  the  patient 

B 


A 

g!j 

i 

l^iiSitimA^.jl^ 

1 

w 

^ 

'..Ife 

hk.:^ 

J 

Fig.  2.— Lumbard's   Nasal   Tubes.     A,    PuU-size  tube   for  aduU; 
B,  tubes  in  use. 

breathes  it.     With  this  apparatus  anesthesia  is  maintained  with  from 
two  to  four  ounces  of  ether  per  hour. 

The  vapor  method  is  valualile  in  operations  about  the  head,  neck, 
and  mouth,  since  the  vaporized  ether  can  be  administered  through 
nasal  tubes  such  as  those  of  Lumbard  (see  Fig.  2)  with  the  an- 
aesthetist removed  some  distance  from  the  site  of  the  operation,  or 
the  Lumbard  tubes  may  be  used  in  connection  with  the  Gwathmey 
apparatus.  The  ano?sthetic  may  be  administered  through  a  bent  metal 
tube  placed  in  the  mouth  or  a  mouth-gag  which  is  provided  with  per- 
forated tubes  along  the  blades  may  be  used  in  these  cases,  and  has 


GEXERAL  COJN'SIDERATIONS. 


the  additional  advantage  of  being  a  mouth-gag  at  the  same  time 
(Fig  3). 

Oxygen  may  be  nsed  as  the  medium  instead  of  air  in  ether  or 
chloroform  ana?sthesia.  For  this  purpose  the  Gwathmey  apparatus 
may  be  used,  the  rubber  tube  from  the  hand  bulb  or  foot  pump  being 
disconnected  and  applied  to  the  oxygen  tank.  The  oxygen  thus 
passes  through  the  ether  or  chloroform  bottles  to  the  mask.  This 
plan  gives  a  safe  and  satisfactory  anaesthesia. 

The  administration  of  ether  may  be  preceded  by  nitrous  oxide  up 
to  the  point  of  unconsciousness  and  loss  of  resistance,  when  the  ether 
is  gradually  substituted.  Ethyl  chloride  may  be  used  for  children 
instead  of  nitrous  oxide.  This  plan  eliminates  the  struggling  and 
excitement  of  the  first  stage  and  represents  less  ether  used. 


Fig.  3. — Mouth-gag  with  Perforated  Tubes  along  Blades.  Arrow  A  indi- 
cates ends  of  tubes  to  which  the  rubber  tubes  carrying  the  ansesthetic  vapor  are 
attached. 

It  is  desirable  in  most  cases  as  a  routine  practice  to  administer, 
half  an  hour  before  commencing  the  angesthetic,  a  dose  of  morphin 
g]\  Ve  to  ^/^  and  atropin  gr.  V150  to  ^Aoo-  The  patient  goes  under 
the  anaesthetic  more  readily  and  less  ether  is  required  to  keep  him 
under.  This  is  especially  true  of  alcoholics  and  athletes.  This  pre- 
liminary dose  may  be  omitted  in  the  very  young  and  in  the  old  and 
feeble. 

Rectal  Administrafio)!  of  Ether  has  been  resorted  to  Avith  varying 
degrees  of  satisfaction  for  operations  upon  the  head,  neck,  and  mouth. 
The  Gwathmey  apparatus  may  be  used  for  this  method  of  ansesthesia. 

Chloroform. — Chloroform  may  be  administered  by  the  open  or 
drop  method,  using  a  Schimmelbusch  mask  and  a  drop  bottle,  or  it 
may  be  administered  in  vapor  form  by  forcing  a  current  of  air 
through  a  bottle  of  cliloroform.  The  Junker  apparatus  or  one  of  its 
modifications  is  used  for  this  purpose.     The  vaporized  chloroform  is 


ANAESTHESIA. 


9 


taken  up  by  the  air  that  is  forced  through  the  liquid  cliloroform  in 
the  bottle  b}^  compressing  the  bulb. 

Gwathmey's  apparatus,  already  described,  is  very  satisfactory  for 
the  administration  of  chloroform,  and  is  provided  with  means  for 
warming  the  anaesthetic.  Oxygen  may  be  forced  through  the  bottles 
instead  of  air,  and  thus  we  may  obtain  oxygen-chloroform  anaesthesia. 

A'^arious  sequences  and  combinations  of  chloroform  and  ether 
and  nitrous  oxide  and  oxygen  may  be  used  in  special  cases,  and  these 


Fig.  4. — Junker  Chloroform  Apparatus 


mixtures  give  ven-  satisfactory  and  safe  anaesthesia.  Special  ap- 
paratus and  special  familiarity  with  the  effects  of  the  various  mixtures 
are  required  in  order  to  obtain  successful  results  with  these  com- 
binations. 

During  the  course  of  ether  or  chloroform  ana?sthesia  oxygen 
may  be  administered  in  varying  quantity.  This  will  often  contribute 
mucli  to  the  safety  of  anaesthesia  in  cases  that  would  be  hazardous 
otherwise. 

Intratracheal  Anaesthesia.  The  Insufflation  ]\Iethod  of 
Melzer  and  Auee.- — This  is  unquestionably  a  most  valuable  method 
for  maintaining  anaesthesia  during  the  course  of  operations  that  neces- 
sitate opening  the  thoracic  cavity.    Ether,  chloroform,  or  nitrous  oxide 


10  GENERAL  CONSIDERATIONS. 

and  oxygen  ma}'  be  administered  in  this  way.  With  ether  and  chloro- 
form the  percentage  of  ether  and  chloroform  must  be  lower  than 
when  administered  in  the  ordinary  way  through  the  mouth  and  nose — 
with  ether  the  degree  of  saturation  is  not  more  than  10  per  cent. 
Several  different  forms  of  apparatus  have  been  constructed, — those  of 
Elsberg,  Janewa}',  Cotton-Boothby.  The  essentials  of  the  intratracheal 
apparatus  are :  a  source  of  air  supply,  which  may  be  obtained  either  by 
use  of  a  foot-pumj)  or  electric  motor;  a  bottle  containing  water 
through  which  the  air  passes;  a  second  bottle  containing  ether  over 
or  through  which  the  air  is  forced  in  order  to  secure  its  percentage  of 
ether  vapor,  and  a  manometer  and  safety  valve  to  register  the  pressure 
of  the  vapor  and  the  intrapulmonary  pressure,  and  to  allow  for  the 
escape  of  any  pressure  above  the  desired  degree.  Air  filters,  warmers, 
etc.,  are  very  desirable  parts  to  the  apparatus,  but  are  not  necessarily 
essential. 

The  patient  is  first  angesthetized  in  the  usual  manner,  and  then  a 
catheter  is  passed  into  the  larynx  and  down  into  the  trachea  as  far 
as  the  bifurcation.  The  catheter  is  marked  at  a  point  26  cm. 
from  the  end,  and  it  is  introduced  into  the  trachea  until  this  point 
is  opposite  the  teeth.  The  catheter  is  a  loose  fit  in  the  trachea  and 
lar}Tix,  so  that  there  is  ample  space  for  the  air  that  is  forced  into  the 
trachea  to  escape  from  the  larynx  around  the  catheter. 

The  catheter  may  be  introduced  by  direct  inspection  through 
a  Chevalier  Jackson  lar3'ngoscope  or  by  means  of  a  tunneled  intro- 
ducer such  as  the  Cotton-Boothby.  If  the  catheter  is  introduced  by 
direct  inspection  a  sterilized  silk-woven  catheter  is  used.  If  intro- 
duced by  means  of  the  Cotton-Boothb}^  introducer  a  soft-rubber 
catheter  is  employed.  ISTo.  22  is  appropriate  for  most  adults.  Ko. 
24  may  ba  used  in  those  cases  where  it  is  desirable  to  inhibit  to 
some  extent  the  escape  of  air  around  the  tube,  where  it  is  im- 
portant to  maintain  a  higher  degree  of  intrapulmonary  pressure;  for 
example,  in  operations  upon  the  lungs,  oesophagus,  etc.,  that  neces- 
sitate opening  the  thoracic  cavity.  In  any  given  case,  if  the  catheter 
is  not  sufficiently  large,  the  lungs  may  be  kept  inflated  by  occasion- 
ally making  a  moderate  degi^ee  of  pressure  with  the  fingers  upon 
the  sides  of  the  larynx  at  the  level  of  the  thyroid  cartilage.  This 
may  be  done  as  often  as  necessary  to  keep  the  lungs  sufficiently 
inflated. 

With  practice  the  introduction  of  the  catheter  into  the  trachea 
becomes  a  matter  of  comparative  ease. 


ANAESTHESIA.  H 

It  is  important  that  the  pressure  of  the  air,  as  it  enters  the 
trachea,  should  not  exceed  20  millimetres  of  mercury. 

A  steady,  continuous  stream  of  air  charged  with  ether,  or  what- 
ever anaesthetic  is  being  used,  is  forced  through  the  catheter  into  the 
trachea.  The  ether-charged  air  mixes  with  the  air  in  the  bronchi 
and  lungs  and  is  free  to  escape  alongside  the  catheter  from  the  trachea 
and  lannx.  No  effort  is  made  to  imitate  the  usual  rhythm  of  inspira- 
tion and  expiration.  In  cases  where  the  thorax  is  open  the  lungs  are 
seen  to  be  in  a  condition  of  partial  inflation,  which  may  be  increased 
or  diminished  if  desired  by  increasing  or  diminishing  the  pressure 
of  the  gas  as  it  enters  the  trachea.  By  compressing  the  larynx  with 
the  fingers  upon  the  thyroid  cartilage,  and  thus  preventing  the 
free  escape  of  the  gas  from  the  larynx  around  the  catheter,  the  lungs 
may  be  inflated  up  to  their  full  capacity. 

This  method  of  anaesthesia  demands  familiarity  ^\ath  the  special 
apparatus  required  and  special  skill  in  introducing  the  catheter  into 
the  larynx  and  trachea.  With  practice  the  introduction  of  the  catheter 
becomes  a  matter  of  comparative  ease.  It  is  necessary  that  skill  and 
judgment,  based  upon  experience,  l)e  used  in  regulating  the  quantity 
of  the  anesthetic  and  the  pressure  under  which  it  is  introduced  into 
the  trachea. 

Local   Anaesthesia. — The  skin   nuiy   be   anesthetized   sufficiently 
for  simple  incision  or  puncture  l)y  freezing,  either  by  the  application, 
of  ice,   chopped   and  mixed   with  salt,   in   a   bag,   or  by  the   ethyl- 
chloride  spray. 

Ethyl  chloride  is  a  very  volatile  substance,  Ijoiling  at  the  body 
temperature.  It  is  supplied  in  glass  cylinders  with  a  removable 
brass  cap.  If  the  cylinder  is  held  in  the  hand  for  a  few  moments 
sufficient  heat  is  imparted  to  volatilize  the  fluid  in  the  cylinder,  which 
then  escapes  in  the  form  of  fine  spray.  The  spray  is  directed  against 
the  part  to  be  anaesthetized  for  a  few  minutes. 

Local  anesthesia  may  be  ol)tained  by  the  use  of  solutions  of 
cocain  or  some  of  its  substitutes. 

Cocain  is  not  as  satisfactory  as  some  of  its  allied  preparations. 
It  spoils  upon  boiling,  and  therefore  it  is  difficult  to  insure  its 
sterility.  Alone  and  in  too  large  dosage,  it  may  cause  dangerous, 
and  even  fatal,  vasomotor,  cardiac,  and  respiratory  disturbance,  with 
cyanosis,  mental  excitement,  delirium ;  weak,  rapid,  irregular  pulse ; 
slow,  shallow  respiration.  Combined  ^N-ith  adrenalin,  it  can  be  used 
with  safety  in  relatively  large  doses.     One  grain  of  cocain  in  %  psr 


13  GENERAL  CONSIDERATIONS. 

cent,  solution  np  to  3  grains  in  ^/^o  per  cent,  solution  may  be  used. 
The  weaker  the  solution,  the  greater  the  quantity  of  the  drug  that  may 
be  given  with  safety. 

Eucain  is  less  toxic  than  cocain,  and  its  solutions  can  be  boiled 
without  spoiling.  It  is  not  as  poAVerful  an  analgesic  as  cocain.  It 
is  used  in  combination  with  adrenalin  and  may  be  used  in  double 
the  quantity  as  cocain. 

Novocain  is  not  so  powerful  an  analgesic  as  cocain,  but  has  a 
low  degree  of  toxicity  and  can  be  boiled.  It  is  employed  in  combina- 
tion with  adrenalin,  and  can  be  used  in  much  stronger  solutions  and 
larger  quantities  than  cocain.  It  is  very  satisfactory  for  inducing 
local  anassthesia. 

Stovain  is  less  toxic  than  cocain.  It  does  not  stand  boiling 
as  well  as  eucain  or  novocain.  It  is  a  favorite  drug  for  inducing 
spinal  analgesia. 

Tropacocain  is  the  safest  and  best  drug  for  inducing  spinal 
analgesia.  It  is  not  desirable  to  add  adrenalin  to  solutions  for  spinal 
injection.     Solutions  of  tropacocain  can  be  boiled. 

A^arious  other  substances,  such  as  solutions  of  urea,  quinine,  etc., 
have  been  recommended  from  time  to  time  as  very  efficient  local 
anfesthetics. 

The  mucous  membranes  may  be  anaesthetized  by  direct  applica- 
tion of  the  analgesic  solution;  the  conjunctiva  by  the  instillation  of 
a  few  drops  of  4  per  cent,  solution  of  cocain  or  novocain;  the  nose  and 
throat  by  swabbing  or  spraying;  the  larynx  by  swabbing  with  a  10 
or  15  per  cent,  solution. 

The  skin  is  rendered  analgesic  by  injecting  the  solution  into 
this  layer  and  the  deeper  parts  by  injecting  each  succeeding  layer  of 
tissue  as  it  is  exposed  during  the  course  of  the  dissection.  This  is 
known  as  the  infiltration  method. 

Anaesthesia  of  a  given  area  may  be  obtained  by  injecting  the 
solution  into  the  nerves  that  supply  the  part  that  is  to  be  operated 
upon.  The  solution  is  injected  into  the  nerves  proper,  or  into  the 
sheaths  of  the  nerves  or  the  tissues  immediately  surrounding  the 
nerves.  The  nerves  may  be  treated  in  this  manner  as  they  are  ex- 
posed during  the  course  of  the  operation,  or  the  solution  may  be 
injected  before  beginning  the  operation,  before  incising  the  skin, 
down  into  the  region  of  the  nerve  that  supplies  the  part  to  be  operated 
upon,  with  the  object  of  introducing  the  solution  directly  into  the 
nerve-trunk  or  into  the  tissues  immediately  surrounding  the  nerve. 


ANAESTHESIA.  13 

The  effect  of  the  analgesic  solution  is  still  more  pronounced  if  it 
can  be  confined  to  the  part  by  interrupting  the  circulation  by  means 
of  a  rubber-elastic  ligature;  for  example,  in  operations  upon  the  ex- 
tremities by  tying  a  rubl:)er  band  about  the  limb  al)0ve  the  site  of 
operation. 

Infiltration  Method. — For  operations  that  require  a  limited 
amount  of  dissection  cocain  in  a  Vio  per  cent,  solution,  introduced 
into  the  skin  hypodermically,  is  very  satisfactory.  The  solution 
should  be  thrown  into  the  deeper  layer  of  the  skin  proper,  so  as  to 
raise  welts,  ard  not  into  the  loose  tissue  underneath  the  skin,  and 
should  be  introduced,  a  few  drops  at  a  time,  through  a  succession 
of  punctures  along  the  line  of  the  proposed  incision.  After  the  first 
puncture  and  injection  have  been  made  the  need'.e  is  introduced 
each  succeeding  time  through  the  skin  that  has  already  been  an- 
festhetized.  After  the  skin  has  been  incised  the  deeper  layers  are 
injected  as  they  are  met  with  during  the  progress  of  the  operation. 

A  satisfactory  solution  is  made  as  follows : — ■ 

Cocain  hydroeliloiid gr.  j. 

Adrenalin   ( 1  to  1000)    tri  xv. 

Salt  solution  (gr.  j  to  5J  )    5ij. 

This  makes  approximately  a  ^/^o  per  cent,  solution,  and  2  to  4 
ounces  (equal  to  1  to  2  gTains  of  cocain)  may  be  used  during  the 
course  of  an  operation,  the  amount  depending  upon  the  age,  etc., 
of  the  patient.  Xovocain  is  a  very  satisfactory  substitute  for  cocain, 
and  has  several  advantages  over  the  latter.  It  can  be  used  in  stronger 
solution — 1/4  per  cent. — and  in  greater  quantity.  Adrenalin  is  added 
to  the  solution  in  the  proportion  of  7  minims  to  the  ounce.  An 
all-glass  syringe,  capable  of  being  boiled  and  with  a  capacity  of  10 
c.c,  is  used.    The  syringe  should  be  boiled  in  water  free  from  soda,  etc. 

ScHLEiCH  Method. — The  solution  used  contains  cocain  and  mor- 
phin.  It  is  thrown  into  the  skin  with  a  hypodermic,  as  described 
above  for  cocain,  along  the  course  of  the  intended  incision.  The  solu- 
tions vary  in  strengih  according  to  the  amount  of  cocain  that  they 
contain,  and  are  known  as  jSTos.  1,  2,  and  3. 

Solution  Xo.  1. 

Cocain  muriate   gm.  0.2  gr.  iij. 

]\Iorphin  muriate    gm.  0.025  gi'.  %• 

Sodium  chloride    gm.  0.2  gr.  iij. 

Sterile  water   c.c.  100.0  Siii%- 

This  is  the  strongest  solution.  A  quantity  up  to  6  drams  may 
be  used. 


14  C4EXERAL  CONSIDERATIONS. 

SOLL'TIO>"^   No.    2. 

C'ocain  muriate   gm.       0.1  gi\  iss. 

^lorphin  muriate    gm.        0.025  gi".  %■ 

Sodium  chloride    gm.       0.2  gr.  iij. 

Sterile  water   c.c.    100.0  fiii%. 

This  is  the  sohition  that  is  commonly  used,  and  of  this  a  qnan- 
tit)'  up  to  3  ounces  may  he  injected. 

SOLUTIOX  No.    3. 

Cocain  muriate gm.  0.01  gr.  %. 

]\Iorpliin  muriate    gm.  0.025  gr.  %. 

Sodium  chloride    gm.  0.2  gr.  iij. 

Sterile  water   c.c.  100.0  Biii%. 

Xo.  3  is  the  weakest  sokition,  containing  only  one-tenth  as 
much  cocain  as  'No.  2.    A  pint  of  this  solution  can  be  used. 

Eegioxal  Anaesthesia. — Certain  regions  may  be  rendered  an- 
algesic by  injecting  a  solution  of  cocain  or  some  of  its  substitutes 
directly  into  the  sensory  nerves  that  supply  the  part.  The  skin  is  first 
anaesthetized,  as  described  above,  the  skin  incised,  and  each  sensory 
nerve  sought  for  and  injected  as  it  is  exposed  during  the  course  of 
the  operation.  A  solution  of  cocain,  %  to  1  per  cent.,  or  a  3  per 
cent,  solution  of  novocain,  with  adrenalin  15  minims  to  the  ounce 
added,  is  employed.  This  plan  is  used  with  success  in  abdominal 
section,  appendicitis,  hernia,  operations  for  goitre,  etc.  In  operating 
for  inguinal  hernia,  for  instance,  the  skin  is  first  anaesthetized  by  the 
infiltration  method,  and  then  after  this  layer  has  been  incised  the 
nerves  that  supply  the  parts — ^the  hypogastric  branch  of  the  ilio- 
hypogastric, the  ingaiinal  branch  of  the  ilio-inguinal,  and  the  genital 
branch  of  the  genito-crural — are  injected  according  as  they  are  ex- 
posed. 

Regional  analgesia  may  also  be  obtained  by  injecting  the  analgesic 
solution  through  the  unbroken  skin  down  into  the  region  of  the  sensory 
nerve-trunks  that  supply  the  part,  depositing  the  solution  directly 
in  the  nerve-trunk  or  in  the  tissues  immediately  surrounding  the 
nerve.  In  this  way  the  median,  ulnar,  external  popliteal,  and  the 
anterior  and  posterior  tibial  nerves  may  be  temporarily  paralyzed 
and  the  parts  supplied  by  them  rendered  free  from  pain.  Amputa- 
tion may  be  thus  done  without  pain  and  with  little  or  no  shock. 
A  rubber  ligature  is  placed  about  the  upper  part  of  the  limb.  The 
same  plan  of  anaesthesia  is  illustrated  when  the  digital  nerves  are 
injected  prior  to  amputation  of  fingers,  toes,  operations  on  ingrowing 
nails,  etc. 


DIVISION  OF  THE  TISSUES.  15 

Spinal  Anaesthesia  (Analgesia). — Aufpstliesia  of  the  lower  part 
of  the  body  may  be  obtained  by  throwing  the  analgesic  solution  into 
the  spinal  subarachnoid  space  by  means  of  a  hypodermic  syringe.  This 
method  of  inducing  analgesia  was  introduced  by  Bier.  A  5  per  cent, 
solution  of  stovain  or  tropacocain  in  salt  solution  is  employed. 
Stovain  is  not  so  stable  as  tropacocain  upon  boiling;  15  to  20  minims 
(1  c.c.)  of  this  solution,  equivalent  to  %  to  1  grain  of  the  drug, 
being  introduced  according  to  the  age,  physical  condition,  etc.,  of  the 
patient.  This  is  the  usual  dose  for  an  adult.  An  all-glass  syringe, 
which  is  capable  of  being  boiled,  with  a  bevel,  slip  nozzle,  and  with 
a  capacity  of  2  c.c.  (30  minims)  is  used.  The  needle  is  made  of 
p.atinum-iridium,  9  to  10  cm.  long,  and  with  a  diameter  of  1  mm. 
The  bevel  of  the  needle  at  the  point  is  short.  The  needle  is  fitted 
with  a  stylet.  The  syringe  and  needle  are  both  boiled  in  pure  water, 
free  from  soda,  etc..  before  using. 

The  puncture  is  made  in  the  lumbar  region,  usually  between 
the  third  and  fourth  spines,  or  the  injection  may  be  made  between 
the  first  and  second  lumbar,  or  between  the  twelfth  dorsal  and  first 
lumbar.  Anaesthesia  of  the  lower  limbs,  abdomen,  and  the  lower  part 
of  the  chest  is  obtained.  It  is  desirable  to  administer,  by  hypodermic 
injection,  one-half  hour  before  the  spinal  injection  is  made,  V^  grain 
of  morphin  and  Vioo  grain  of  hyoscin  to  quiet  the  patient.  (See 
"Lumbar  Puncture,"'  page  541.) 

DIVISION  OF  THE  TISSUES. 

Division  of  the  Soft  Parts. — Bloody  Dr'isiox  of  the  Soft 
Parts. — The  division  of  the  integument  may  be  accomplished  with 
the  knife  or  scissors,  either  by  direct  incision  or  by  transfixion 
(Fig.  5).  The  deeper  soft  parts  may  be  divided  with  cutting  instru- 
ments or  by  tearing  with  the  fingers  or  blunt  instruments,  the  handle 
of  the  scalpel,  thumb  forceps,  etc.  This  plan  of  blunt  dissection  is 
especially  serviceable  in  enucleating  encapsulated  tumors  or  lymphatic 
nodes  and  in  separating  between  different  layers  of  tissue  along  the 
normal  connective-tissue  planes. 

The  contents  of  hollow  viscera,  serous  spaces,  and  cystic  tumors 
may  be  evacuated  or  withdrawn  in  part  for  the  purpose  of  diagnosis 
by  means  of  the  trocar  and  cannula  or  some  form  of  aspirating  ap- 
paratus. Substances  may  also  be  introduced  into  the  body  through 
cannulge  or  with  some  form  of  syringe. 


16  GENERAL  CONSIDERATIONS. 

Bloodless  Division  of  tlie  Soft  Pakts. — This  result  ma}^  be 
accomplished  witli  the  thermocautery,  galvanocautery,  elastic  liga- 
ture, ecraseur,  or  wire  snare,  and  by  the  action  of  corroding  chemicals. 

Division  of  Bone. — ^Bones  may  be  divided  through  an  incision 
in  the  soft  parts  with  the  chisel  and  mallet,  bone  forceps,  or  with 
some  form  of  saw, — circular,  chain,  or  wire,  or  with  the  flat  saw ;  with 
the  drill,  dental  burr,  or  bone  scoop.  The  De  Vilbiss,  Hudson,  Dahl- 
gren  forceps  are  very  satisfactory  instruments  for  the  purpose  of  divid- 
ing the  bone  in  making  large  bone-flaps  in  the  skull.  The  bones  are 
covered  with  an  adherent  vascular  membrane,  the  periosteum,  which 
should  be  incised  with  the  knife  and  separated  from  the  bone  with 
the  elevator  before  applying  the  cutting  instruments  to  the  bone. 

The  bone  may  be  divided  without  an  incision  in  the  soft  parts 
— for  the  purjDose  of  correcting  deformities,  etc. — either  by  manual 


f 

Fig.  5. — Division  of  the  Skin  by  Transfixion. 

force  or  by  the  use  of  an  instrument  knoAvn  as  the  osteoclast.  The 
osteoclast  consists  of  a,  solid  metal  bar  with  two  sliding  bracelets, 
one  on  either  end,  and  between  these  a  brace  which  may  be  raised  or 
lowered  by  means  of  a  screw. 

HEMORRHAGE. 

During  the  course  of  an  operation  the  hemorrhage  must  be  con- 
trolled in  order  to  minimize  the  loss  to  the  patient  and  to  keep  the 
field  clear  for  proper  work. 

Hemorrhage  may  be  described  as  capillary,  venous,  and  arterial. 

Capillary  hemorrhage  is  characterized  by  a  general  oozing. 

Venous  hemorrhage  is  characterized  by  a  steady  welling  of  blood 
into  the  wound,  often  filling  it  so  as  to  obscure  the  bleeding  point. 
Venous  blood  is  rather  darker  in  color  than  arterial  blood.  If  a  large 
vein  is  divided  close  to  the  trunk, — i.e.,  in  the  neck  or  axilla, — or  if 
one  of  the  intracranial  dura  mater  sinuses  is  opened,  the  blood  may 


HEMORRHAGE.  17 

escape  in  a  remittent  stream,  synchronous  witli  the  respiratory  move- 
ments, diminishing  or  ceasing  during  inspiration  and  increasing  dur- 
ing expiration.  During  inspiration,  under  these  circumstances,  air 
may  be  sucked  into  the  veins,  but,  if  limited  in  quantity,  tliis  Avill 
not  result  in  any  harm ;  nevertheless  it  should  be  guarded  against. 

Arterial  hemorrhage  is  characterized  by  the  brighter  color  of  the 
blood  and  by  the  fact  that  it  escapes  in  a  distinct  remittent  jet  of 
considerable,  though  varying,  force.  The  jet  is  synchronous  with 
the  heart's  action,  increasing  during  ventricular  systole  and  diminish- 
ing during  ventricular  diastole. 

Means  to  Arrest  Hemorrhage. — The  Natural  Arrest  of  Hem- 
orrhage is  effected  by  the  clotting  of  the  b^ood.  If  the  divided 
vessels  are  not  too  large  and  the  blood-pressure  not  too  great,  nature 
will  thus  be  able  to  bring  about  a  cessation  of  the  hemorrhage.  Nature 
is  assisted  in  her  efforts  to  control  hemorrhage  from  a  severed  artery 
by  the  fact  that  when  an  artery  is  divided  its  orifice  contracts,  thus 
diminishing  the  size  of  the  opening  through  which  the  blood  escapes, 
and  further  by  the  fact  that  the  inner  elastic  coat  of  the  vessel, 
the  intima,  retracts,  coiling  up  within  the  artery,  thus  blocking  the 
lumen  of  the  vessel  and  offering  a  considerable  impediment  to  the 
flow.  As  the  hemorrhage  continues  the  blood-pressure  becomes  pro- 
gressively less  and  less,  and  this  is  an  important  factor  in  the  natural 
arrest  of  hemorrhage.  Where  hemorrhage  has  ceased  spontaneously 
caution  should  be  exercised  in  administering  cardiac  stimulants,  intra- 
venous saline  infusion,  etc.,  because  as  a  result  of  raising  the  blood- 
pressure  the  hemorrhage  may  be  renewed.  This  fact  is  to  be  borne  in 
mind,  especially  in  hemorrhage  from  internal  parts,  ruptured  ectopic 
pregnancy,  hemorrhage  from  lungs,  stomach,  intestine,  etc.,  while 
the  source  of  the  hemorrhage  is  not  directly  accessible. 

The  natural  arrest  of  hemorrhage  from  a  severed  vein  is  facili- 
tated by  the  low  blood-pressure  within  the  vessel  and  by  the  col- 
lapsibility  of  its  thin,  flaccid  wall. 

Artificial  Arrest  of  Hemorrhage. — Artificial  measures  are 
usually  resorted  to,  in  order  to  control  hemorrhage.  These  may  be 
classified  as  indirect  means,  acting  outside  at  a  distance  from  the 
wound,  and  direct  means,  acting  locally  within  the  wound. 

Indirect  Means.  The  Elastic  Bandage  'and  Constrictor 
(Esmarcli ). — Operations  upon  the  extremities  may  be  rendered  prac- 
tically bloodless  by  the  use  of  the  Esmarch  bandage  and  constrictor. 

2 


18 


GENERAL  CONSIDERATIONS. 


The  extremity  being  elevated,  a  rubber  bandage  about  three 
inches  broad  is  applied  about  the  limb,  each  turn  being  draAvn  pretty 
tight.  The  bandage  is  applied  spirally  about  the  limb,  commencing 
below  and  working  upward  toward  the  trunk,  each  turn  somewhat 
overlapping  its  predecessor;  in  this  way  the  blood  is  forced  out  of 
the  limb.  Having  reached  a  point  above  the  site  of  the  proposed 
operation,  a  rubber  band  or  thick  elastic  tube,  the  constrictor,  is 
passed  around  the  limb  several  times  and  then  made  fast.  The  rubber 
spiral  bandage  may  then  be  removed.  In  most  cases  the  application 
of  the  rubber  spiral  bandage  may  be  dispensed  with,  it  being  sufficient 
to  elevate  the  limb  to  a  perpendicular  position  for  a  few  minutes, 
at  the  same  time  massaging  or  stripping  it  from  the  periphery  toward 
the  trunk,  in  order  to  force  the  bulk  of  the  blood  out  of  it.     While 


Fig.  6. — Bsmarch  Bandage  and  Constrictor.    The  constrictor  is  provided 
witli   a   chain   and   hook. 


the  limb  is  thus  elevated,  the  rubber  constrictor  bandage  is  applied 
about  the  upper  part  of  the  limb. 

In  cases  of  tuberculous  disease,  malignant  disease,  and  sepsis 
one  should  certainly  omit  stripping  the  limb  or  applying  the  rubber 
spiral  bandage  on  account  of  the  likelihood  of  forcing  infectious 
elements  onward  into  the  healthy  tissues.  Under  these  circumstances 
one 'should  be  content  with  elevation  of  the  limb  for  a  few  minutes 
before  applying  the  constrictor. 

The  rubber  constrictor  that  is  placed  about  the  limb  may  be 
secured  with  a  strip  of  gauze  which  is  placed  underneath  the  con- 
strictor so  that,  after  the  first  loop  of  an  ordinary  knot  has  been  taken 
in  the  constrictor,  the  gauze  strip  may  be  tied  over  this  to  secure  it  and 
prevent  it  from  slipping;  the  second  and  final  loop  is  then  taken 
in  the  rubber  constrictor.  The  constrictor  shown  in  the  illustration 
is  provided  with  ^  chain  and  hook. 

The  constrictor  should  be  applied  sufficiently  tight  to  shut  off 
the  arterial  current,  but  not  tight  enough  to  bruise  the  nerve-trunks 
against  the  underlying  bone. 


HEMORRHAGE.  19 

For  operations  upon  the  lower  extremity,  except  at  the  hip-joint, 
the  constrictor  is  placed  about  the  thigh,  just  above  the  knee-joint 
or  higher  up.  nearer  the  hip-joint.  For  disarticulation  at  the  hip- 
joint  the  constrictor  is  placed  about  the  limb  as  high  up,  near  the 
trunk,  as  possible,  and  it  is  then  prevented  from  slipping  down  by 
steel  pins,  or  skewers,  which  are  passed  through  the  soft  parts 
(Wyeth). 

For  operations  upon  the  upper  extremity,  except  at  the  shoulder- 
joint,  the  ligature  is  placed  about  the  arm,  just  above  the  elbow- 
joint  or  higher  up  nearer  the  shoulder-joint.  For  disarticulation  at 
the  shoulder-joint  the  constrictor  is  applied  as  high  up  as  possible; 
it  may  be  passed  through  the  axilla  and  over  the  shoulder  and  pre- 
vented from  slipping  by  a  steel  pin,  or  skewer,  that  is  thrust  through 
the  soft  parts,  transfixing  the  upper  part  of  the  deltoid  muscle  mass. 

The  main  arterial  and  venous  trunks,  if  they  have  been  divided 
during  the  course  of  the  operation,  may  be  secured  and  ligated  before 
the  constrictor  is  removed.  Any  additional  bleeding  branches  may 
be  secured  and  ligated  after  the  constrictor  has  been  removed. 

By  Digital  Compression  of  the  Main  Arterial  Trunk  at  a  Dis- 
tance from  the  Site  of  the  Operation. — ^During  amputation  of  the 
thigh  the  common  femoral  arteiy,  as  it  emerges  from  under  Poupart's 
ligament,  may  be  compressed  against  the  underlying  pubic  iDone. 

During  amputation  of  the  forearm  or  disarticulation  at  the 
elbow-joint  the  brachial  may  be  compressed  against  the  humerus,  and 
during  amputation  through  the  upper  arm  or  at  the  shoulder- joint 
the  hemorrhage  may  be  controlled  by  digital  compression  of  the  sub- 
clavian artery  against  the  first  rib.    This  plan  is  rather  untrustworthy. 

Preliminary  Ligation  in  Continuity. — ^This  is  a  very  satisfactory 
method  of  controlling  hemorrhage  in  certain  bloody  operations.  For 
example,  in  disarticulation  at  the  hip-joint  preliminary  ligation  of 
the  common  femoral  may  be  practiced,  the  vein  being  tied  at  the  same 
time  through  the  same  incision.  In  amputation  of  the  tongue  one 
or  both  Unguals  may  be  ligated  as  a  preliminary  step  to  the  main 
procedure.  In  extirpation  of  the  lower  jaAV,  etc.,  preliminary  ligation 
of  the  external  carotid  may  be  practiced  with  great  advantage. 

Position. — Position  of  the  part  has  much  to  do  with  the  severity 
of  the  hemorrhage  diiring  an  operation.  Elevation  of  the  part  is 
often  sufficient,  of  itself,  to  check  capillary  and  venous  hemorrhage. 
The  volume  of  arterial  blood  sent  to  the  part  is  diminished  and  the 
retum-flow  through  the  veins  is  facilitated.     These  factors,  together. 


20 


GEXERAL  CONSIDERATIONS. 


serve  to  markedly  diminish  the  pressure  in  all  the  vessels  of  the 
elevated  part.  This  is  especially  true  of  the  limbs,  but  also  of  the 
pe'vis  and  the  head.  With  the  pelvis  raised  as  in  the  Trendelenburg 
position,  the  hemorrhage  during  the  course  of  operations  upon  the 
pelvic  organs  is  much  diminished.  During  operations  upon  the  head, 
face,  and  neck  it  will  be  found  that  the  hemorrhage,  especially  the 
venous,  is  very  much  less  with  the  patient  in  the  semi-erect  position 


Fig.  7. — Trendelenburg  Position. 


than  it  would  be  with  the  patient  in  the  Eose  position,  with  the  held 
hanging  low  over  the  end  of  the  table. 

Direct  Means  of  Controlling  Hemorrhage  are  applied 
within  the  wound  itself,  and  these  may  be  divided  into  three  groups : 
Agents  that  act  locally  through  the  nervous  system;  chemical  agents 
that  act  directly  upon  the  escaping  blood,  causing  it  to  coagulate; 
and  mechanical  agents. 

Agents  that  Act  Locally  Through  the  Nervous  System. — Applica- 
tion of  heat  or  cold,  usually  in  the  form  of  water,  hot  or  cold,  or  ice, 


HEMORRHAGE.  21 

tends  to  diminisli  ami  check  heniorrliafre.  If  hot  water  is  used  it 
should  be  as  hot  as  tlie  liand  can  bear,  about  130°  F. ;  if  cohl,  it  should 
be  quite  cold. 

Heat  and  cold  both  act  by  causing  the  small  arterioles  to  con- 
tract and  diminish  in  size.  Heat  causes  albumin  to  coagulate  so  that, 
when  heat  is  applied  to  a  wound,  the  wound  surface  becomes  glazed 
with  a  thin,  albuminous  film,  and  in  this  way  heat  possesses  an  addi- 
tional potency  in  checking  oozing.  Heat  is  a  more  effective  agent 
in  controlling  hemorrhage  than  cold,  since  the  latter  acts  only  by 
causing  a  diminution  in  caliber  of  the  small  arteries. 

Heat  in  the  form  of  a  hot  saline  irrigation  is  a  very  satisfactory 
agent  to  check  oozing  from  capillaries  and  small  arteries  and  veins. 
A  very  effective  means  is  pressure  with  a  gauze  compress  wrung  out 
in  very  hot  water. 

Chemical  Agents.  Sfi/piicy. — These  agents  tend  to  check  hem- 
orrhage by  acting  directly  upon  the  escaping  blood,  causing  it  to 
coagulate,  and  thus  seal  the  mouths  of  the  severed  vessels.  They 
are  but  little  used  except  in  operations  upon  the  nose,  etc.,  and  are 
of  service  only  to  control  capillary  hemorrhage  and  oozing  from 
small  veins  and  arteries.  The  common  styptics  are  the  persulphate 
of  iron,  tincture  of  the  chloride  of  iron,  powdered  alum,  tannic  acid, 
etc.  The  styptic  cotton  is  ordinary  absorbent  cotton  impregnated  with 
one  of  these  agents. 

Adrenalin,  applied  locally  in  1  to  1000  solution,  is  a  very  prompt 
and  effective  means  of  controlling  hemorrhage  by  causing  contraction 
of  the  arterioles. 

Mechanical  Means.  Dif/ital  Compression. — With  the  finger 
in  the  wound  hemorrhage  may  be  controlled  by  pressure  exerted 
directly  upon  a  severed  vessel,  thus  closing  it  until  it  can  be  secured 
with  an  artery  forceps.  In  operations  upon  the  neck,  for  example, 
a  large  vessel  may  be  divided  and  then  so  obscured  by  the  great 
volume  of  escaping  blood  that  it  cannot  be  located  and  secured  with 
the  artery  forceps.  With  the  finger  thrust  into  the  wound  the  hem- 
orrhage may  be  checked  temporarily  by  compressing  the  injured 
vessel  until  the  wound  can  be  cleared  of  blood  and  the  vessel  located 
and  grasped  with  an  artery  clamp.  This  is  especially  true  of  large 
veins;  when  cut,  the  blood  may  well  into  the  Avound  in  such  volume 
that  one  is  unable  to  locate  the  divided  vessel. 

Digital  compression  may  be  applied  to  the  main  vessels  in  the 
wound  before  they  are  divided  in  order  to  minimize  the  loss  of  blood. 


22  GENERAL  CONSIDERATIONS. 

For  example,  in  exartic-ulating  at  the  shoulder-joint,  after  the  incisions 
have  heen  made,  but  Ijefore  the  brachial  artery  and  adjoining  vessels 
have  been  cut,  the  assistant  grasps  the  mass  of  soft  parts  which  in- 
cludes the  main  vascular  trunks  and  compresses  these  between  the 
thumb  and  fingers  until  after  the  limb  has  been  amputated  and  the 
vessels  secured  by  the  operator. 

Tamponade. — This  is  really  one  way  of  applying  the  principle 
of  compression.  This  method  is  especially  sei-viceable  im  con.trolliiig 
oozing  and  bleeding  from  veins.  For  example,  hemorrhage  from  an 
injured  intracranial  sinus  may  be  readily  controlled  by  packing  a 
strand  of  gauze  into  the  Avound  between  the  sinus  and  the  skull,  hem- 
orrhage from  the  uterus  by  packing  the  uterus. 

If  an  abscess  cavity  or  a  cavity  in  a  bone  is  tamponed  and  a 
good  snug  dressing  applied  so  as  to  exert  a  considerable  degree  of 
firm  compression,  this  will  usually  suffice  to  check  all  oozing  from 
capillaries  and  small  veins. 

Bleeding  from  the  nutrient  artery  of  a  bone  may  be  checked 
by  plugging  the  orifice  of  the  nutrient  canal  with  a  piece  of  catgut 
or  a  wooden  peg.  Oozing  from  the  end  of  a  long  bone,  from  the 
edges  of  the  bones  of  the  skull  in  craniotomy,  etc.,  is  readily  con- 
trolled by  a  few  minutes'  firm  compression  with  a  hot  gauze  pad. 
Occasionally  the  hemorrhage  from  the  edges  of  the  bone  in  craniotomy 
"is  excessive  and  i^ersists.  Under  these  circumstances  it  can  be  con- 
trolled by  applying  Horsley's  wax,  a  putty-like  substance  composed  of 
vaselin,  paraffin,  and  carbolic  acid.  The  wax  is  smeared  against 
the  edges  of  the  bone. 

Suture  of  the  Wound  controls  hemorrhage  from  capillaries  and 
small  veins  by  bringing  the  contiguous  surfaces  into  apposition,  and 
is  simply  one  method  of  applying  the  principle  of  compression. 

Forcipresswe  consists  in  crushing  the  coats  of  the  severed  ves- 
sels with  haemostatic  forceps.  It  is  a  well-knoAvn  fact  that  even  large 
arteries  when  crushed  or  torn  do  not  bleed,  and  it  is  upon  this  same 
principle  that  forcipressure  is  applied  to  control  hemorrhage.  The 
bleeding  artery  or  vein  is  seized  with  the  forceps,  which  is 
then  closed  down  upon  the  vessel  Avith  much  force,  in  this  way  crush- 
ing the  coats  of  the  vessel,  especially  the  inner  coat,  and  so  effectually 
controlling  the  hemorrhage.  If  the  vessels  are  small  the  forceps  may 
be  removed  after  a  few  minutes,  when  it  will  be  found  that  the  hem- 
orrhage has  ceased.  Forcipressure  is  a  very  satisfactory  method  of 
dealing  with  larger  vessels  when  situated  deep  in  a  small  wound  where 


HEMORRHAGE.  23 

they  are  not  readily  accessible  for  ligation.  Under  these  circum- 
stances, however,  it  is  wise  to  allow  the  forceps  to  remain  in  place 
for  twenty-four  to  forty-eight  hours,  including  them  in  the  dressing, 
since  the  hemorrhage  might  recur  if  they  were  removed  earlier.  By 
allowing  the  forceps  to  remain  one  gives  the  blood  a  chance  to  form 
a  good  firm  clot  to  occlude  the  vessels. 

Torsion. — This  method  of  occluding  a  bleeding  vessel  consists 
in  seizing  the  end  and  twisting  it  until  the  inner  coat  of  the  vessel 
is  ruptured  and  the  end  of  the  vessel,  in  the  grasp  of  the  forceps, 
is  twisted  free.     This  measure  may  be  applied  to  small  arteries  and 


Fig.  8.— Square   Knot.  Fig.  9.— Slip-knot. 


Fig.  10. — Surgeon's  Knot.     The  first  loop  is  made  double  to  prevent  slipping 
while  taking  the  second  loop. 

veins  as  an  adjunct  to  forcipressnre.  Torsion  may  be  more  effectually 
applied  by  grasping  the  free  end  of  the  vessel  with  one  forceps  and 
the  vessel  itself  a  short  distance  beyond,  transversely,  with  a  second 
forceps.  While  the  vessel  is  steadied  with  the  forceps  that  grasps  it 
transversely,  it  is  twisted  repeatedly  upon  itself  with  the  forceps  that 
grasps  its  extremity. 

Ligature. — The  most  commonly  employed  and  safest  means  of 
securing  several  arteries  and  veins,  especially  if  of  large  calibre.  In 
the  day  of  the  non-absorbable,  non-aseptic  ligature  many  plans  were 
devised  to  obviate  the  use  of  the  ligature,  since  it  had  to  be  cast  off  be- 
fore the  wound  could  heal,  and  thus  precluded  the  possibility  of  union 
by  first  intention,  and  because,  as  the  ligature  separated  and  came 
away,  it  was  often  accompanied  by  a  dangerous  secondary  hemorrhage. 


24  GENERAL  CONSIDERATIONS. 

^Yith  the  aseptic,  absorbable  ligature,  an  ideal  method  of  controlling 
hemorrhage  in  the  Avound  was  instituted.  The  aseptic,  absorbable  liga- 
ture permits  the  immediate  closure  of  the  wound  and  does  not  in  any 
way  interfere  with  the  healing  process.  Some  surgeons  still  use  silk  for 
ligature.  Although  silk  may  be  rendered  absolutely  aseptic,  it  has  the 
disadvantage  of  not  being  absorbable,  and  may  therefore  occasionally 
act  as  a  foreign  body,  keeping  the  Avound  open  until  it  separates  or  until 
it  is  removed.  The  ligatures  may  be  applied  to  the  exposed  vessels 
before  they  have  beeii  divided  or  afterward,  and  may  be  applied  to 
the  isolated  vessels  or  may  include  the  immediately  adjoining  soft 
parts  as  well. 

Ligature  of  blood-vessels  before  they  have  been  severed  is  ex- 
emplified in  the  tying  of  the  external  jugular  in  operations  uj)on  the 
neck  after  the  A^essel  has  been  exposed  in  the  incision,  but  before  it 
is  cut;  the  ligature  is  applied  double  and  the  A^essel  then  divided 
between  these.  Again,  in  disarticulation  through  the  hip- joint  the 
main  vessels  may  be  exposed  during  the  course  of  the  operation, 
ligated,  and  then  divided.  In  resecting  portions  of  the  alimentary 
canal  the  mesentery  or  omentum  that  carries  the  blood-supply  to 
the  parts  must  be  tied  off.  This  is  usually  done  '  in  sections,  each 
ligature  including  from  one  to  one  and  a  half  inches  of  the  mesen- 
tery or  omentum;  in  this  case  not  only  are  the  blood-vessels  included 
in  the  ligatures,  but  all  of  the  tissue  from  one  ligature  to  the  next. 

Ordinarily  the  ligatures  are  applied  to  the  vessels  after  they 
have  been  severed.  The  bleeding  point  is  seized  Avith  a  hgemostatic 
forceps  and  the  ligature  is  then  slipped  over  the  end  of  this  and  tied. 

Occasionall}^  vessels  in  dense  fibrous  tissue,  in  the  dura  mater 
and  wall  of  the  chest,  when  cut,  retract  into  the  surrounding  tissue 
so  that  tlieir  ends  cannot  be  seized  with  the  forceps.  Under  these 
circumstances  it  may  be  necessary  to  carry  the  ligature  around  the 
vessel  with  a  curved  needle. 

Treatment  of  Severe  Hemorrhage. — After  the  hemorrhage  has 
been  controlled  by  ligation,  tampon,  etc.-,  it  may  be  necessary  to  re- 
place the  blood  Avhich  has  been  lost  by  infusion  of  normal  salt  solution 
or  by  direct  transfusion  of  blood  from  another  person. 

Intravexous  Saline  Infusion. — Any  prominent  superficial  vein 
may  be  used  for  this  purpose;  the  median  cephalic  at  the  bend  of  the 
elboAV  is  the  one  usually  selected.  A  tourniquet  or  bandage  is  first 
applied  about  the  arm,  high  up  near  the  axilla  and  just  sufficiently 
tight  to  constrict  the  superficial  veins,  but  not  tight  enough  to  shut 


HKMORRHAGE.  25 

off  the  arterial  current;  this  causes  the  superficial  veins  to  become 
swollen  and  more  conspicuous.  The  skin  is  then  pinched  up  over 
the  vein  and  may  be  incised  by  transfixion  with  the  knife  or  with 
the  scissors,  care  being  taken  not  to  injure  the  vein  itself.  The 
vein  is  then  plainly  exposed   and  thoroughly  isolated  for  less  than 


Fig.  11. — Superficial  Vein  Exposed  for  Saline  Infusion.  The  vein,  which 
is  raised  upon  the  director,  has  been  surrounded  by  two  ligatures  and  opened 
ready  to  introduce  the  cannula.  The  lower  ligature  has  been  tied.  The  upper 
ligature  has  not  been  tied;  one  loop  of  the  knot  has  been  taken,  but  not  drawn 
tight. 

one  inch  and  raised  well  out  of  its  bed  upon  a  director,  after  which 
a  double  catgut  ligature  is  passed  around  the  vein.  This  ligature 
is  then  cut,  so  as  to  leave  the  vein  surrounded  by  two  ligatures,  one 
above  and  the  other  below.  The  lower  ligature  is  tied.  A  single 
loop  of  a  knot  is  taken  loosely  in  the  upper  ligature,  the  ends  of  which 
are  left  long.     The  vein  is  then  freely  opened  with  a  narrow-bladed 


26 


GENERAL  COXSIDERATIOXS. 


knife,  or  the  vein  may  be  picked  up  with  the  thumb  forceps  and 
snipped  half  across  with  the  scissors.  The  vein  bleeds.  Through 
the  opening  made  in  the  vein  the  end  of  the  cannula,  with  the  saline 
solution  floT^dng  from  it,  is  slipped  up  into  the  vein  beyond  the  uj^per 
ligature,  which  is  then  tied  fast  about  the  cannula,  in  order  to  retain 
it  securely  in  j^lace  within  the  vein. 

Deli])erate  care  should  be  taken  to  introduce  the  cannula  into  the 
lumen  of  the  vein,  and  not  into  the  loose  connective  tissue  that  sur- 


DONOPv 


RECIPIENT 


w  '•j~\-  ^\-<^\  ^v\v. 


Fig.  12.— Plan  of  Arrangement  of  Tables,   Patients,   Operator,   etc.,  in 
Arterio- venous  Transfusion. 


rounds  the  vein.  This  is  an  accident  which  may  readil)'^  occur  and 
is  to  be  avoided  by  thoroughly  isolating  the  vein  and  lifting*  it  well 
out  of  its  bed  before  incising  it.  Before  the  cannula  is  introduced  into 
the  vein  the  solution  should  be  allowed  to  flow,  and  thus  avoid  carry- 
ing air  into  the  vein;  although  it  is  of  no  consequence  if  a  small 
•quantity  of  air  does  enter  the  vein,  nevertheless  this  should  be  avoided 
if  possible. 

After  the  cannula  has  been  introduced  into  the  vein  and  secured 
by  tying  the  ligature,  the  bandage  is  removed  from  the  upper  part 
of  the  arm  and  the  fluid  allowed  to  flow.  From  1000  to  1500  c.c. 
at  a  temperature  of  115°   F.  may  be  introduced.     The  fluid  should 


HEMORRHAGE.  27 

not  be  pennitted  to  flow  too  rapidly.  Ten  minutes  should  be  allowed 
for  1000  to  1500  c.c.  The  reservoir  is  held  at  an  elevation  of  about 
two  feet. 

The  saline  infusion  acts  by  restoring  the  arterial  pressure  and 
the  character  of  the  pulse  is  a  good  guide  as  to  the  quantity  of 
fluid  to  be  introduced.  The  solution  may  be  made  in  emergency  by 
dissolving  a  heaping  teaspoonful  of  salt  in  one  quart  of  water. 

ArTERIO- VENOUS  ANASTOMOSIS  OF  BLOOD-TESSELS  FOR  TRANSFU- 
SION", Carrel's  Operatiok. — The  transfusion  of  blood  from  one  per- 
son to  another  can  only  be  accomplished  with  safety  when  the  intima 
of  the  vessel  of  the  one  is  continuous  with  the  intima  of  the  vessel 
of  the  other.  The  blood  must  not  come  in  contact  with  foreign 
material  or  tissues.  The  anastomosis  may  be  made  with  suture  or 
with  Crile's  cannula.  The  donor  and  the  recipient  rest  upon  tables 
placed  side  by  side  with  their  feet  in  opposite  directions.  The  ta- 
bles are  provided  with  movable  head-pieces  that  may  be  lowered  or 
raised  in  the  event  of  cerebral  angemia  or  acute  cardiac  dilatation. 
The  left  arm  of  each  patient  rests  upon  a  small  square  table  which 
is  of  the  same  height  as  the  large  tables  and  placed  between  them. 
The  operation  is  done  under  local  anaesthesia,  a  solution  of  ^/\c  of 
1  per  cent,  of  cocain,  to  which  a  small  quantity  of  adrenalin  is  added, 
being  used.  The  solution  is  injected  into  the  skin  and  then  deeper 
into  the  tissues  about  the  vessels..  It  is  advisable  to  administer  to 
each  patient,  half  an  hour  before  the  operation,  ^^  grain  of  morphin 
hypodermically.  The  face  of  each  patient  is  covered  with  a  damp 
towel  for  psychic  effect  and  to  shut  off  vision  and  allay  nervousness. 
Special  instruments  are  required  for  the  operation:  3  or  4  pair  of 
narrow,  fine-pointed  artery  forceps,  mosquito  forceps,  for  catching 
the  ends  of  the  vessels;  2  pair  of  fine-pointed  dissecting  forceps;  fine- 
pointed  straight  scissors;  2  Crile  clamps  for  temporarily  compressing 
the  vessels;  several  very'  fine,  straight  needles  (Xo.  16,  Kirby's  English 
needles)  threaded  with  very  fine  strands  of  silk  for  suture ;  Xo.  1 
Chinese  twisted  silk  is  unravelled  into  its  component  strands  in  order 
to  get  threads  sufficiently  fine  to  enter  the  minute  eye  of  the  needle. 
The  entire  operation  must  be  done  with  extreme  gentleness  and 
deliberation. 

Suture  Method. — The  donor's  radial  artery  is  exposed  at  the 
wrist  and  freed  from  its  bed  for  a  distance  of  3  cm.  Every  bleeding 
vessel  is  clamped  so  that  the  field  is  absolutely  free  from  blood.  In 
isolating  the  radial  artery  every  branch  that  is  given  off,  no  matter 


28 


GEXEEAL  CONSIDERATIONS. 


how  small,  is  ligatecl  and  divided  so  that  the  vessel  is  entirely  free 
for  a  distance  of  3  cm.  The  portion  of  the  artery  which  is  thus  ex- 
posed is  ligated  at  the  distal  end,  and  a  Crile  clamp  placed  upon  the 
proximal  part  and  screwed  down  gently  so  as  to  exert  just  enough 
pressure  to  control  the  flow  of  blood.  The  artery  is  divided  close  to 
the  ligature  and  cut  square  across  with  sharp,  straight  scissors.  The 
outer  coat  of  the  arter}^,  the  adventitia,  is  seized  with  the  dissecting 
forceps,  pulled  down  over  the  end  of  the  artery,  and  cut  off,  square, 
with  the  sharp,  straight  scissors.     The  adventitia  then  retracts  still 


Fig.   13. — Arterio-venous  Anastomosis,   Suture  Method. 


farther  and  thus  leaves  a  free  margin  for  the  introduction  of  the 
sutures.  The  free  end  of  the  radial  arter}^,  about  2.5  cm.,  is  thus 
ready  for  the  anastomosis. 

The  vein  of  the  recipient,  usually  the  median  basilic,  is  exposed 
and  treated  in  a  similar  manner,  ligated,  a  Crile  clamp  applied,  the 
vein  divided  close  to  the  ligature,  and  it  is  then  ready  for  the 
anastomosis. 

The  ends  of  the  vessels  are  brought  sufficiently  close  to  each 
other  and  are  joined  by  three  sutures  of  the  finest  silk,  placed  equi- 
distant apart.  These  sutures  penetrate  all  the  coats  of  the  vessels 
and,  when  tied,  bring  the  ends  of  the  vessels  close  together  at  three 
points  equidistant  apart.     These  sutures  are  left  long  to  serve  as 


HEMORRHAGE. 


29 


tractors.  When  tension  is  made  on  the  tractor  sutures  the  ends  of 
the  artery  and  vein  which  have  heen  joined  together  form  an  equi- 
lateral triangle.     (A,  B,  C,  Fig.  13.) 

The  ends  of  the  artery  and  vein  are  joined  together  by  a  con- 
tinuous suture  of  the  finest  silk  carried  in  the  finest  straight  needle 
(Kirby's  English  needle,  Xo.  16).  Tlie  suture  is  soaked  in  sterile 
vaselin   or  oil.     By  making  traction   upon  two  tractor  sutures   and 


CrUe's   Cannulse. 


hanging  a  weight  (mosquito  forceps)  on  the  third,  the  introduction 
of  the  suture  is  facilitated  and  the  danger  of  picking  up  the  opposite 
wall  of  the  vessels  in  passing  the  needle  is  obviated.  In  this  way 
the  vessels  for  one-third  of  their  circumference  are  sutured  together. 
The  succeeding  thirds  of  their  circumference  are  sutured  in  the  same 
manner,  this  being  facilitated  by  changing  the  suspended  hemostat 
to  the  next  tractor  suture  and  making;  traction  with  the  other  two. 


Fig.  15. — Arterio-venous  Anastomosis  with  Crile's  Cannula,  etc. 

The  sutures  are  applied  very  close  together,  and  very  close  to  the 
edges  of  the  artery  and  vein,  except  in  the  neighborhood  of  the  tractor 
sutures,  where  they  take  a  broader  bite  in  order  to  secure  the  vessels 
beyond  the  holes  made  by  the  tractor  sutures.  When  the  anastomosis 
has  been  completed  the  clamps  are  removed,  first  from  the  vein  and 
then  from  the  artery,  and  the  l)lood  allowed  to  flow. 

During  the  operation  and  while  the  blood  is  flowing,  the  vessels 
are  kept  constantly  moist  with  warm  saline  solution. 


30  GENERAL  CONSIDERATIONS. 

With  the  Ceile  Cannula. — The  cannu^ge  consist  of  short  metal 
cylinders,  the  external  surface  divided  into  two  portions  by  a  ridge 
that  passes  around  the  middle.  A  similar  ridge  marks  each  end  of  the 
cannula.  There  are  four  sizes;  the  smallest  has  a  diameter  of  1.5 
mm.,  the  next  2  mm.,  the  next  3.5  mm,.,  and  the  largest  3  mm.  (about 
%  inch).  The  cannula  is  provided  with  a  handle  near  one  end  by 
which  it  may  be  conveniently  held  in  the  grasp  of  an  artery  forceps. 


Fig.  16.— Arterio-venous   Anastomosis   with   Crile's   Cannula,    etc. 

There  is  no  difficulty  in  finding  a  vein  sufficiently  large  to  ac- 
commodate a  large  cannula;  the  difficulty  is  that  the  artery  may  be 
found  rather  small.  The  artery  must  not  be  stretched  unduly  in 
drawing  it  over  the  end  of  the  vein  upon  the  cannula;  the  intima 
must  not  be  injured.  The  size  cannula  to  be  used,  therefore,  will 
depend  upon  the  size  of  the  artery.  If  too  large  a  vein  is  used  for 
the  size  cannula  selected  it  will  become  folded  upon  itself  within 
the  lumen  of  the  cannula,  will  occupy  too  much  room,  and  thus  ob- 
struct the  flow  of  blood. 

The  vessels  are  exposed  and  treated  as  has  already  been  described 
in  the  "Suture  Method."  The  end  of  the  vein  is  secured  with  a 
silk  suture  and  pulled  through  the  cannula  (Fig.  15).    The  end  of  the 


HEMORRHAGE. 


31 


rein  which  has  been  thus  pulled  through  the  cannula  is  seized  with  three 
mosquito  forceps,  taking  a  firm  hold,  but  not  extending  up  into  the 
lumen  of  the  vessel  any  farther  than  necessary,  and  is  turned  back. 


Fig.  17.— Arterio-venous   Anastomosis   with   Crile's   Cannula,    etc. 


Fig.  18.— Arterio-venous   Anastomosis   with   Crile's   Cannula,    etc. 

cufE-fashion,  over  the  cannula,  all  the  way  back  to  the  handle,  and 
is  secured  thus  by  a  ligature  of  fine  silk,  which  is  tied  around  the 
vein  upon  the  cannula  in  the  groove  nearer  the  handle  (Figs.  16  and 
IT) .    The  cannula  is  thus  entirely  covered  over  by  the  cuffed-back  vein. 


32 


GENERAL  CONSIDERATIONS. 


The  surface  of  the  vein  which  has  been  cuffed  back  over  the  cannula 
is  carefully  smeared  with  sterile  vaselin  to  allow  the  end  of  the  artery 
to  be  more  readily  drawn  over  it. 

The  end  of  the  artery  is  next  secured.  It  may  have  contracted, 
and  will  require  very  gentle  dilatation  with  the  end  of  a  mosquito 
forceps,  which  is  smeared  with  vaselin  and  slipped  into  the  end  of  the 
artery.    The  end  of  the  artery  is  secured  with  three  mosquito  hemostats 


Fig.  19. — Brewer's   Transfusion  Tubes. 

and  is  gently  pulled  well  over  the  cuffed  end  of  the  vein'  upon  the 
cannula  (Fig.  17).  The  end  of  the  artery  is  secured  in  position  by 
tying  a  ligature  around  it  in  the  remaining  groove  on  the  cannula 
(Fig.  18). 

The  artery  forceps  which  held  the  cannula  is  now  removed  and 
the  operation  is  complete.  The  clamps  are  removed  first  from  the 
vein  and  then  from  the  artery  and  the  blood  allowed  to  flow. 

There  are  two  important  points  in  using  the  cannula:  (1)  the 
vein  must  be  drawn  straight  through  the  cannula  so  that  the  long 
axis  of  the  cannula  and  long  axis  of  the  vein  correspond  to  each 
other,  otherwise  the  lumen  of  the  vein  just  beyond  the  cannula  will 
be  obstructed  and  interfere  with  the  free  flow  of  blood;  (2)  when  the 


SUTURE  OF  THE  TISSUES.  33 

blood  is  flowing  a  moderate  degree  of  tension  should  be  made  in  the 
direction  of  the  long  axis  of  the  vein,  otherwise  the  wall  of  the  vein 
tends  to  be  drawn  into  the  cannula  and  to  obstruct  the  flow. 

The  donor  must  be  free  from  disease  and  sufficiently  robust  to 
spare  the  blood  required.  The  blood  of  the  donor  must  not  be 
hsemolytic  for  that  of  the  recipient.  It  is  desirable  that  the  blood 
be  tested  beforehand  to  determine  this  fact.  The  quantity  of  blood 
allowed  to  pass  will  depend  upon  a  number  of  conditions,  the  strength 
of  the  donor  and  needs  of  the  recipient.  In  a  general  way  the  pulse, 
etc.,  of  donor  and  recipient  are  good  guides  as  to  quantity.  If  the 
flow  is  too  fast  acute  cerebral  anemia  of  the  donor  or  acute  cardiac 
dilatation  of  the  recipient  may  result.  If  this  occurs  it  will  be  neces- 
sary to  moderate  the  flow  and  lower  the  head  end  of  the  table  of  the 
donor  and  raise  the  head  end  of  the  table  of  the  recipient. 

With  Brewer's  Tubes. — A  simple  and  very  satisfactory  method 
of  transfusion.  The  tubes  are  made  of  glass,  are  of  different  sizes, 
and  are  either  straight  or  with  an  elbow.  The  ends  of  the  blood- 
vessels are  exposed  and  prepared  in  a  manner  similar  to  that  already 
described.  The  tube  is  dipped  in  hot  melted  paraffin  before  using 
and  allowed  to  cool,  and  then  introduced  into  the  blood-vessels.  One 
end  of  the  tube  is  introduced  into  the  artery  and  secured  there  with 
a  ligature  tied  over  the  end  of  the  artery  upon  the  tube.  The  clamp 
is  removed  from  the  artery  and  a  few  jets  of  blood  allowed  to  escape, 
and  the  free  end  of  the  tube  then  introduced  into  the  end  of  the 
vein  and  secured  with  a  ligature, — quite  similar  to  the  plan  of  'in- 
troducing the  cannula  in  intravenous  saline  infusion. 

SUTURE  OF  THE  TISSUES. 

The  various  suture  materials  may  be  grouped  into  two  classes: 
temporary  and  permanent. 

Temporary  sutures  are  made  of  simple  catgut,  which  softens 
and  becomes  absorbed  in  from  five  to  ten  days  according  to  its  thick- 
ness, and  chromicized  catgiit,  which  remains  longer,  from  two  to 
four  Aveeks  or  even  six  weeks,  according  to  its  thickness  and  the 
manner  of  its  preparation. 

Permanent  sutures  consist  of  silk,  silkworm  gut,  kangaroo  ten- 
don, horse-hair  and  metal,  silver  wire,  etc.  (Kangaroo  tendon  be- 
comes absorbed  after  sixty  days ;  so  that  it  is  not,  in  the  strict  sense, 
permanent.) 

3 


34 


GENERAL  COXSIDERATIONS. 


Suture  of  the  Skin. — For  this  purpose  a  stitcli  may  be  used,  con- 
tinuous or  interrupted,  which  penetrates  the  skin,  or  else  a  non- 
penetrating intracuticular  stitch  may  be  employed. 

The  stitch  should  not  be  drawn  too  tight,  as  it  constricts  the 
parts  and  may  thus  interfere  with  the  blood-supply  and  the  healing 
process.  If  the  stitch  is  drawn  too  tight  it  may  cut  its  way  through  the 
tissues,  and  besides  may  add  much  .to  the  pain  and  discomfort  of 
the  patient.  The  stitch  should  be  drawn  just  tight  enough  to  bring 
the  parts  into  immediate  contact.  The  knots  should  be  so  arranged 
that  they  lie  to  one  side  or  the  other  of  the  line  of  the  incision. 


Fig.   20. — Intracuticular  Suture.     A,  pledget  of  gauze, 
fixed  to  end  of  the  suture. 


The  Inteacuticular  Sutuee. — For  this  suture  simple  or 
chromidzed  catgut  or  some  permanent  material — silk-worm  gut,  silk, 
etc. — may  be  used.  This  is  the  most  satisfactor}^  method  of  approx- 
imating the  edges  of  the  skin.  The  resulting  scar  is  very  much  less 
unsightly,  and  the  danger  of  stitch  abscess  is  reduced  to  a  minimum. 
The  stitch  is  introduced  with  a  straight  needle  or  with  a  curved 
needle  in  a  holder;  a  straight  Hagedorn  needle  is  preferable.  In  in- 
troducing this  stitch  it  is  necessary  to  catch  the  firm  under-layer  of 
the  skin  proper — not  the  loose  subcutaneous  fat  and  connective 
tissue — and  to  take  a  good  long  bite  with  each  thrust  of  the  needle. 
In  crossing  from  one  edge  of  the  incision  to  the  other,  care  should 
be  taken  to  enter  the  needle  directly  opposite  the  point  at  which 
it  emerged.  The  suture  may  be  secured  at  each  end  with  a  small 
gauze  pad. 

One  pad  is  fixed  to  the  end  of  the  thread  before  commencing 


SCTURE  OF  THE  TISSUES. 


35 


the  suture,  and  then,  after  the  needle  emerges  througli  the  last  punc- 
ture^,  it  is  carried  through  the  second  pad  and  the  suture  secured 
with  one  or  two  stitches  in  this. 

Suture  of  Muscle. — Divided  muscle  is  usually  approximated  with 
absorbable  nuiterial. — simple  or  chromicized  catgut.  If  the  muscle 
has  been  cut  across,  at  right  angles  to  the  course  of  its  fibers,  the 
part  should  be  placed  in  a  position  to  relax  the  muscle  and  special 
care  should  be  exercised  to  bring  the  cut  edges  securely  together. 
This  is  accomplished  by  introducing  a  sufficient  number  of  inter- 
rupted sutures   or  a  continuous  suture  of  moderately  thick   catgut, 

A  B 


Fig. 


21. — Suture  of  Tendon.     A,  ends  of  divided  tendon  united  with  mattress  suture; 
B,  upper  end  of  tendon  split  and  turned   down  to  meet  lower  end. 


each  t-aking  a  good  secure  bite  in  the  muscle,  or  several  mattress 
sutures  may  be  used  for  this  purpose.  If  the  muscle  has  been  divided 
along  the  course  of  its  fibers, — i.e.,  between  its  fibers, — several  in- 
terrupted catgut  sutures  will  usually  suffice  to  retain  its  edges  in 
apposition. 

If  the  sheath  of  a  broad  muscle  has  been  divided, — for  exam- 
ple, the  sheath  of  the  rectus, — care  should  be  taken  to  reunite  the 
edges  of  the  sheath  accurately  with  chromicized  catgut. 

In  operations  for  the  cure  of  hernias  the  edges  of  the  muscles 
or  of  the  aponeurosis  are  united  with  a  non-absorbable  suture  ma- 
terial,— silk,  silk-wonn  gut.  kangaroo  tendon,  or  silver  wire, — with 
the  idea  of  leaving  these  as  permanent  sutures  to  retain  the  parts 
in  close  apposition  for  a  considerable  length  of  time. 


36 


GENERAL  CONSIDERATIONS. 


Suture  of  Tendons. — Severed  tendons  are  sewed  end  to  end  with 
fine,  ten-day  chromicized  catgnt.  A  single  mattress  suture  or  one 
or  more  ordinary  interrupted  sutures  that  pass  through  the  tendon 
proper  are  usually  employed  for  this  purpose.  If  a  part  of  the  tendon 
has  been  destroyed  so  that  the  ends  cannot  he  approximated,  a  flap 
may  be  turned  back  from  one  or  both  ends  in  order  to  meet  this 
deficiency. 


Fig.  22.— Bone  Drill  with  Eye  Near  the  Point  to  Carry  Suture,  etc. 

Suture  of  Nerves. — The  ends  of  a  divided  nerve  may  be  joined 
with  one  or  two  plain  catgut  sutures  which  secure  the  sheath  of  the 
nerve,  or,  better,  these  sutures  may  penetrate  the  nerve  proper,  the 
essential  point  being  to  bring  the  ends  of  the  nerve  into  immediate 
contact.  Ill  old  cases  it  will  be  necessary  to  freshen  the  ends  of  the 
nerves  before  suturing. 


Fig.  23. — Segment  of  Bowel.     Interrupted 
Lambert   sutures    in   place. 


Fig.  24. — Segment  of  Bowel.  Lembert 
sutures  tied.  It  will  be  noted  that  they 
do  not  penetrate  through  the  entire 
thickness  of  the  wall  of  the  gut. 


Bone  and  Cartilage. — For  the  purpose  of  suturing  bone  and 
cartilage  '  silver  wire  is  usually  employed.  Sometimes  heavy,  chro- 
micized catgut  or  kangaroo  tendon  is  used.  In  order  to  pass  the 
sutures,  holes  must  first  be  made  through  the  bone.  This  is  done 
with  the  drill.  Before  withdrawing  the  drill  the  suture  is  intro- 
duced through  the  small  eye  in  the  jDoint  of  the  drill,  and  then  as 
the  instrument  is  withdrawn  it  brings  the  suture  after  it.     If  the 


SUTURE  OF  THE  TISSUES. 


37 


suture  is  too  thick  to  enter  the  eye  in  the  point  of  the  drill,  a  loop 
of  silk  may  be  passed  through  the  eye  of  the  drill  and  the  suture 
drawn  through  with  this. 

Bones  are  sometimes  joined  with  one  or  more  sutures  of  chro- 
micized  catgut  or  kangaroo  tendon  which  do  not  go  through  the 
bone,  but  include  the  periosteum  and  the  fibrous  tissue  that  cover 
the  bone ;  this  method  may  be  used,  for  example,  to  unite  a  fractured 
patella  so  as  to  avoid  entering  the  knee-joint  and  the  handling  that 
would  be  necessary  in  the  making  of  drill-holes. 

Fragments  of  bone  may  also  be  joined  by  steel  nails,  ivory  pegs, 
etc.,  that  are  driven  from  one  fragment  of  bone  into  the  other,  or 
the  fragments  may  be  held  together  by  metal  plates, — Lane's  plates, — 


Halsted"s 


Suture. 


Pig.  25. — Gushing  Suture  Applied  to 
Close  Opening  in  the  Bowel.  It  is  a  con- 
tinuous stitch  and  passes  through  the 
■wall  of  the  gut  parallel  with  the  line  of 
the  incision  instead  of  at  right  angles  to 
it. 

which  bridge  across  the  fracture  and  are  secured  by  being  screwed 
to  the  fragments. 

Suture  of  Serous  Surfaces,  Bowel,  etc. — The  essential  object  is 
to  secure  rapid  adhesion  by  approximating  serous  surface  to  serous 
surface,  and  this  is  accomplished  by  means  of  the  Lembert  suture. 

The  Lembert  suture  catches  the  serous  and  muscular  coats  of 
the  bowel,  but  does  not  penetrate  into  the  mucous  membrane  layer. 
It  should  not  enter  into  the  lumen  of  the  gut,  etc.  For  this  suture 
silk  should  be  employed.  It  may  be  introduced  interrupted  or  con- 
tinuous, and  is  applied  in  such  a  manner  as  to  invert  the  edges  and 
join  opposite  serous  surfaces. 

A  straight,  round,  cambric  needle  is  usually  employed  to  carry 
the  Lembert  suture,  but  occasionally,  especially  in  sewing  deep  within 


38 


GENERAL  CONSIDERATIONS. 


the  abdominal  cavity,  a  thin,  curved,  surgeon's  needle  in  a  holder  may 
be  more  convenient. 

In  apjDlying  the  Lembert  suture  the  needle  is  introduced  a  short 
distance  from  the  edge  of  the  ojDening  in  the  bowel,  and  after  passing 
in  the  wall  of  the  gut  for  a  short  distance  and  catching  up  the  serous 
and  muscular  coats,  but  not  entering  the  mucous  membrane  coat, 
it  emerges  near  the  edge  of  the  wound  in  the  gut;  the  needle  is  then 
carried  across  the  opening  in  the  bowel  and  introduced  upon  the 
other  side  at  a  point  directly  opposite  and  in  a  similar  manner. 

The  suture  mav  also  be  introduced  and  carried  in  the  wall  of 


Fig.  27.— Xon-penetrating  Suture. 


the  gut  along  a  line  parallel  with  the  incision  instead  of  at  right 
angles  to  the  line  of  the  incision, — ^the  Gushing  suture. 

Small  wounds  of  the  bowel  may  be  closed  with  a  single  row  of 
Lembert  sutures  or  vnth  a  Lembert  suture  in  the  shape  of  a  purse- 
string.  Larger  wounds  of  the  hollow  abdominal  viscera  should  be 
closed,  first  with  a  continuous  or  interrupted  row  of  No.  1,  ten-day, 
chromic  catgut  sutures  that  penetrate  through  all  the  layers  of  the 
organ,  joining  the  parts  accurately  edge  to  edge,  and  then,  after  the 
opening  has  Ijeen  thu'S  closed,  the  Lembert  stitch,  which  unites  the 
opposite  serous  surfaces  to  each  other,  is  applied.  The  Lembert  stitch 
buries  the  penetrating  suture  and  inverts  the  edges  of  the  wound, 
so  that  the  serous  surfaces  become  apposed  to  each  other.  The  out- 
side Lembert  suture  that  buries  the  deeper  penetrating  mucous  suture 
is  sometimes  called  the  '^outside  serous"  suture. 


SUTURE  OF  THE  TISSUES.  39 

Suture  of  Wounds  of  the  Bladder. — Closure  of  wounds  of 
the  urinary  bladder  requires  special  mention.  They  may  involve 
the  serous  or  the  non-serous  portion  of  the  organ. 

Wounds  of  the  serous  portion  should  be  closed  first  with  a  con- 
tinuous catgT.it  stitch,  No.  1,  ten-day  chromicized,  which  should  in- 
clude all  the  coats  except  the  mucous  membrane.  Each  loop  of  this 
suture  should  be  drawn  tight.  This  sei-ves  to  close  the  opening. 
These  sutures  do  not  penetrate,  hence  do  not  appear  upon  the  inner 
surface  of  the  bladder.  A  continuous  Lembert  stitch  of  silk  is  then 
introduced  which  unites  the  opposite  serous  surfaces,  immediately 
adjacent  to  the  edges  of  the  incision,  to  each  other  and  buries  the 
first  row  of  sutures. 

Wounds  of  the  non-serous  portion  of  the  bladder:  i.e.,  its  ante- 
rior wall.  Wounds  of  this  part  of  the  bladder  should  be  closed  with 
a  continuous  or  interrupted  row  of  No.  1,  ten-day  chromicized  cat- 
gut sutures  that  include  the  whole  thickness  of  the  bladder  wall 
except  its  mucous  membrane  layer.  These  sutures  should  close  the 
opening  in  the  wall  of  the  bladder  very  accurately ;  owing  to  the  absence 
of  the  serous  coat  from  this  part  of  the  bladder,  the  Lembert  suture — 
"outside  serous  suture" — cannot  be  applied.  Since  we  cannot  look  for 
rapid  adhesion  in  wounds  of  this  part  of  the  bladder,  it  is  well  to 
allow  the  abdominal  incision  to  remain  partly  open,  packing  with 
gauze  down  to  the  suture  line  in  the  wall  of  the  bladder,  so  that,  if 
there  is  any  leakage,  the  fluid  may  find  its  way  out  of  the  wound. 


PART  II. 

HEAD  AND  FACE. 


HEAD. 


Surgical  Anatomy  of  the  Head.  The  Scalp  — The  head  is  cov- 
ered b}'  the  scalp,  which  is  a  dense  ]a3'er,  composed  of  the  skin, 
subciitaneons  connective  tissue,  and  the  aponeurosis  of  the  occipito- 
frontalis  muscle.     These  three  layers  together  constitute  the  scalp. 

The  subcutaneous  connective  tissue  is  dense  and  serves  to  unite 
the  skin  intimately  with  the  underlying  aponeurosis  of  the  occipito- 
frontalis  muscle.  It  is  continuous  behind,  in  front,  and  upon  the 
sides  with  the  superficial  fascia  (subcutaneous  fatty  and  connective- 
tissue  layer)  of  these  parts.    In  it  ramify  the  blood-vessels  and  nerves. 

The  arteries  of  the  scalp  are  large  and  numerous.  Bleeding 
from  these  vessels  can  often  be  controlled  by  pressure  applied  against 
the  underljdng  bony  surface.  Anteriorly  are  the  frontal  and  supra- 
orbital arteries;  on  the  sides,  branches  of  the  temporal;  and,  behind, 
the  occipital  and  posterior  auricular.  These  vessels  all  course  from 
below  upward  toward  the  crown  of  the  head,  their  branches  anas- 
tomosing freely  with  each  other  all  around.  These  arteries  are  found 
at  times  to  be  very  tortuous. 

The  occipito-frontalis  muscle  is  broad  and  fiat,  consisting  of 
an  anterior  and  a  posterior  muscular  portion  and  an  intermediate 
aponeurotic  portion  which  covers  the  top  of  the  skull.  This -apo- 
neurosis is  firmly  united  with  the  overlying  skin,  whereas  it  is  but 
loosely  attached  to  the  pericranium  beneath.  Upon  either  side  the 
aponeurosis  is  continued  into  the  temporal  fascia.  In  cases  AA-here 
the  scalp  is  torn  off,  the  aponeurosis  of  the  occipito-frontalis  comes 
away  with  the  skin  and  subcutaneous  connective  tissue,  thus  leaving 
the  pericranium  exposed. 

In  the  temporal  region  the  subcutaneous  connective-tissue  layer 
is  looser  than  upon  the  top  of  the  head,  and  in  it  run  the  branches 
of  the  temporal  artery  and  vein  and  tlie  auriculo-temporal  nerve. 
Beneath  the  subcutaneous  layer  in  the  temporal  region  is  the  tem- 
poral fascia.  This  is  a  strong,  fibrous  layer  covering  in  the  temporal 
(40) 


SURGICAL  ANATOMY  OF  THE  HEAD.  41 

muscle  and  i?  attached  above,  all  around,  to  the  temporal  ridge  and 
below,  to  the  upper  border  of  the  zygomatic  arch,  where  it  splits  into 
two  layers  between  Avhich  are  included  a  small  arterial  and  nervous 
branch.  The  aponeurosis  of  the  occipito-frontalis  muscle  thins  out 
upon  each  side  and  is  continued  into  this  temporal  fascia.  Beneath 
the  temporal  fascia  is  the  temporal  muscle.  This  is  a  broad,  fan- 
shaped  muscle  which  arises  from  the  whole  surface  of  the  temporal 
fossa  and  from  the  under  surface  of  the  temporal  fascia;  it  is  at- 
tached by  a  strong  tendon  to  the  tip,  anterior  border,  and  inner 
surface  of  the  coracoid  process  of  the  inferior  maxilla. 

The  pericranium  is  a  shining,  fibrous  layer  of  periosteum  which 
is  closely  attached  to  the  external  surface  of  the  bones  of  the  skull: 
most  intimately  at  the  suture  lines,  through  which  it  is  continuous- 
with  the  dura  mater  lining  the  inner  surface  of  the  bones. 

Collections  of  pus  or  blood  between  the  skin  and  the  occipito- 
frontalis  aponeurosis  give  rise  to  circumscribed  tumors  because  they 
cannot  become  diffused  in  the  dense  subcutaneous  connective-tissue 
layer.  Between  the  aponeurosis  and  the  pericranium,  however,  such 
collections  may  become  widely  diffused,  owing  to  the  looseness  of  the 
tissue  which  joins  the  aponeurosis  and  the  pericranium  together,  and, 
raising  the  whole  scalp  so  that  it  resembles  a  water-bag,  may  gravitate 
and  point  in  the  frontal  or  occipital  regions.  Beneath  the  pericranium^ 
between  this  layer  and  the  surface  of  the  bone,  such  collections  are 
again  limited,  owing  to  the  close  union  between  this  structure  and 
the  underlying  bone  (see  Fig.  39). 

The  Skull. — The  skull  is  a  rounded,  elastic  case  made  up  of  a 
number  of  bones  joined,  for  the  most  part,  edge  to  edge.  The  base 
of  the  skull  is  irregular  and  is  strengthened  along  certain  lines  by 
ribs  of  bone,  the  intervening  portions  being  often  very  thin.  It 
presents  many  openings  for  the  entrance  and  exit  of  important 
structures. 

The  Vault  of  the  Skull  is  arched,  rounded,  and  smooth.  The 
bones  entering  into  tlie  formation  of  the  vault  are  flat  and  vary  in 
thickness  in  different  places.  These  so-called  flat  bones  that  enter  into 
the  formation  of  the  vault  are  made  up  of  spongy  tissue — diploe — 
inclosed  between  two  plates  of  hard  compact  bone :  the  inner  and 
outer  tables.  The  outer  table  is  twice  as  thick  as  the  inner.  The 
external  surface  of  the  skull  is  covered  by  the  periosteum  (peri- 
cranium) already  mentioned.  The  internal  surface  is  lined  by  the 
dura  mater,  which  is  very  closely  applied  to  the  surface  of  the  bones,  ' 


42  HEAD  AND  FACE. 

serving  the  purpose  of  a  periosteum;  the  large  vascular  branches 
that  ramify  upon  the  inner  surface  of  the  skull  are  lodged  in  the  dura. 

The  spongy  substance — dip^oe — inclosed  between  the  two  layers 
of  compact  bone  presents  an  extensive  system  of  venous  canals.  These 
comniimicate  with  the  intracranial  venous  sinuses  that  are  found 
between  the  layers  of  the  dura  mater,  and  with  the  veins  of  the  scalp. 
The  vault  of  the  skull  varies  in  thickness  in  different  places  and  in 
different  individuals.  About  the  middle  it  is  thin,  its  average  thick- 
ness in  this  situation  being  from  4  to  5  mm. ;  it  becomes  thicker  toward 
the  front  and  still  more  so  toward  the  occiput.  Along  the  course  of 
the  intracranial  venous  sinuses,  and  also  corresponding  to  the  de- 
pressions for  the  Pacchionian  bodies  which  are  located  upon  either 
side  along  the  middle  line,  the  bone  is  thinner.  Where  the  skull  is 
thin  it  is  at  the  expense  of  the  diploe,  which  in  certain  parts  may 
be  entirely  absent,  the  two  tables  being  in  direct  contact  with  each 
other.     This  is  the  condition  in  the  temporal  region. 

The  lines  of  junction  of  the  bones  of  which  the  vault  is  made 
up  are  irregular  and  might  be  mistaken  for  fractures  when  exposed 
in  scalp  wounds.  The  junction  of  the  two  parietal  bones  in  the 
middle  line  forms  the  sagittal  suture.  The  junction  of  the  two 
parietal  bones  with  the  frontal  anteriorly  forms  the  coronal  suture. 
The  point  where  the  coronal  crosses  the  sagittal  suture  is  called  the 
bregma.  This  is  the  site  of  the  anterior  fontanelle,  which  does  not 
close  until  some  time  between  the  eighteenth  and  twenty-fourth 
month.  Occasionally  it  closes  earlier.  The  time  at  which  the  fon- 
tanelle closes  is  of  diagnostic  importance  in  infants.  Posteriorly  the 
parietal  bones  articulate  with  the  occipital  bone  and  forms  the  lamb- 
doidal  suture.  In  the  middle  line,  corresponding  to  the  junction  of 
the  sagittal  and  lambdoidal  suture  lines,  is  the  lambda.  This  location 
may  be  marked  by  the  presence  of  one  or  more  Wormian  bones,  and 
corresponds  to  the  position  of  the  posterior  fontanelle.  The  posterior 
fontanelle  is  found  closed  at  birth  or  closes  shortly  thereafter.  An- 
teriorly, corresponding  to  the  articulation  of  the  nasal  bones  with 
the  frontal  is  a  line  of  suture,  the  fronto-nasal  suture.  Occasionally 
meningocele  (anterior)  protrudes  at  this  site.  Ascending  in  the  mid- 
dle line  for  a  short  distance  from  the  line  of  articulation  between 
the  nasal  and  frontal  iDones,  the  remains  of  a  suture  line  may  be 
seen  which  represents  the  line  of  union  between  the  two  halves  of 
which  the  frontal  bone  originally  consisted.  This  is  called  the  frontal 
suture. 


SURGICAL  ANATOMY  OF  THE  HEAD. 


43 


The  mid-point  of  the  f  roiito-naf^al  suture  is  called  the  nasion.  In 
the  middle  line,  just  ahove  the  nasion,  is  a  prominence,  the  glahella. 
This  is  an  important  surgical  landmark.  Behind,  the  prominent 
external  occipital  protuberance  may  be  readily  felt.  This  is  called 
the  inion.  A  line  corresponding  to  the  sagittal  suture  drawn  from 
the  nasion  to  the  inion  might  be  called  the  sagittal  line.  Passing 
outward,  on  either  side,  from  the  external  occipital  protuberance,  is 


BREGMA 


EXT.  AN6. 
PROCESS 

LABELLA 
NASION 


EID'S 
BASE  LINE 


Fig.  28. — Side  of  the  SkuU.     Shows  various  important  landmarks. 


the  superior  curved  line  of  the  occipital  bone.  The  external  occipital 
protuberance  corresponds  fairly  accurately  to  the  position  of  the  in- 
ternal occipital  protuberance  and  the  superior  curved  line  of  the 
occipital  bone  to  the  level  of  the  attachment  of  the  tentorium  cerebelli, 
course  of  the  lateral  sinus,  etc.  The  prominence  corresponding  to 
the  lambda,  some  distance  above  the  external  occipital  protuberance, 
should  not  be  mistaken  for  the  latter.  A  foetal  suture  extending  up- 
ward in  the  middle  line  from  the  foramen  magnum  may  persist.  This 
is  the  usual  site  of  cranial  meningocele. 


44  HEAD  AND  FACE. 

The  point  on  the  side  of  the  skull,  where  the  anterior  inferior 
angle  of  the  parietal  bone  articulates  with  the  frontal  and  the  great 
wing  of  the  sphenoid,  is  called  the  pterion,  and  is  located  one  and 
one-half  inches  behind,  and  one-quarter  inch  above,  the  external  an- 
gular process  of  the  frontal  bone.  The  pterion  corresponds  to  the 
Sylvian  point  where  the  Sylvian  fissure  breaks  up  into  its  three 
branches,  and  to  the  course  of  the  anterior  branch  of  the  middle 
meningeal.  The  point  where  the  superior  temporal  ridge  crosses 
the  coronal  suture  is  called  the  stephanion.  The  asterion  is  the  point 
where  the  occipital,  mastoid,  and  parietal  bones  meet.  It  corresponds 
to  the  knee  of  the  lateral  sinus.  Two  other  important  landmarks 
are  the  external  angular  process  of  the  frontal  bone,  where  the  frontal 
articulates  with  the  malar,  and  the  preauricular  point  which  corre- 
sponds to  the  upper  border  of  the  root  of  the  zygoma  just  anterior  to 
the  location  of  the  external  auditory  meatus.  Eeid's  base  line  is  drawn 
from  the  lower  margin  of  the  orbit  through  the  upper  margin  of  the 
external  auditory  meatus. 

Frontal  Sinuses.- — 'Corresponding  to  the  frontal  region,  the 
skull  is  marked  by  the  presence  of  two  large  air-spaces,  one  on  either 
side,  the  frontal  sinuses.  The  frontal  sinuses  do  not  become  fully 
developed  until  after  puberty.  They  are  more  prominent  in  the  male 
than  in  the  female.  They  are  separated  from  each  other  by  a  septum 
located  more  or  less  in  the  middle  line.  The  frontal  sinuses  vary 
very  much  in  size  in  different  individuals,  and  in  the  same  individual 
on  either  side.  There  may  be  marked  deviation  of  the  septum^  so 
that  one  sinus  is  very  large  and  extends  over  beyond  the  middle  line, 
the  other  sinus  being  correspondingly  small.  Both  sinuses  may  be 
very  large,  or  one  or  both  may  be  but  slightly  developed  or  absent. 
The  anterior  wall  of  these  spaces  is  thick,  and  consists  of  two  layers 
of  hard,  compact  bone,  with  an  intervening  diploeic  layer.  The  pos- 
terior wall  is  thin.  The  frontal  sinuses  are  lined  with  mucous  mem- 
brane and  communicate  with  the  nasal  fossa  through  a  large  canal, 
the  infundibulum,  which  opens  under  the  middle  turbinated  bone, 
toward  the  front.  The  anterior  ethmoidal  cells  are  in  close  proximity 
to  the  floor  of  the  frontal  sinuses — only  a  thin  plate  of  bone  interven- 
ing— and  these  may  become  involved  in  suppuration  of  the  frontal 
sinuses.  Pus  in  the  frontal  sinus  may  perforate  the  floor  of  the 
sinus  and  point  in  the  upper  inner  angle  of  the  orbit,  or  the  process 
may  extend  through  the  posterior  wall  of  the  sinus  into  the  cranial 
cavity,  and  set  up  a  meningitis,  abscess  in  the  frontal  lobe,  etc. 


SURGICAL  ANATOMY  OF  THE  HEAD. 


45 


The  Side  of  the  Skull. — In  the  mastoid  region  the  bone  is  pro- 
longed downward  in  the  form  of  a  teat-like  process;  the  mastoid 
process  (mastoid  region — see  page  113). 

Corresponding  to  the  temporal  region,  the  skull  is  made  np  of 
the  squamous  portion  of  the  temporal  bone,  which  is  very  thin,  and 
of  part  of  the  parietal  bone.  Ascending  upon  the  surface  of  the 
bone,  beneath  the  temporal  muscle,  are  several  deep  temporal  arterial 
branches. 

The  parietal  and  the  occipital  bones  and  the  mastoid  portion 
of  the  temporal  bone  present  openings  for  the  passage  of  veins  from 


Fig.  29.— Transverse  Section  through  the  Anterior  Fossa.  Shows  the  relation 
of  the  floor  of  the  anterior  fossa  to  the  roof  of  the  orbital  and  nasal  cavities; 
8,  M,  I,  superior,  middle,  and  inferior  turbinate  bones;  IS,  antrum  of  Highmore; 
0,  orbital  cavity;  N,  nasal  cavity. 

the  exterior  of  the  skull  which  empty  into  the  intracranial  sinuses, 
and  these  may  be  the  routes  through  Avhich  infection  is  carried  into 
the  cranial  cavity. 

The  Base  of  the  Skull,  studied  from  within,  is  seen  to  consist  of 
three  f oss^  located  upon  different  levels : — 

The  Anterior  Fossa  is  situated  upon  the  highest  level.  The 
floor  is  made  of  the  cribriform  plate  of  the  etlunoid  in  the  middle, 
and  of  the  frontal  and  the  lesser  wing  of  the  sphenoid  upon  the  sides. 
The  ethmoid  is  perforated  by  numerous  small  openings  for  the  pas- 
sage  of  branches  of  the   olfactorv  nerve   and  blood-vessels,   to   and 


4,e  HEAD  AXD  FACE. 

from  the  nasal  cavity.  The  floor  of  the  anterior  fossa  is  very  thin 
and  corresponds  to  the  roof  of  the  orbital  and  nasal  cavities.  The 
roofs  of  the  various  sinuses  (air-spaces)  adjacent  to  the  upper  part 
of  the  nasal  cavity  are  very  thin  and  correspond  to  the  floor  of  the 
anterior  fossa  of  the  skull.  Disease  of  these  sinuses  may  readily 
extend  to  the  meningeal  membranes  and  to  the  anterior  lobes  of 
the  brain.  There  is  also  danger  of  perforation  in  operating  within 
these  sinuses. 

The  frontal  lobes  rest  upon  the  floor  of  the  anterior  fossa. 
Fracture  of  the  anterior  fossa  is  characterized  by  escape  of  blood 
through  the  nose  or  into  the  orbital  cavities,  with  resulting  subcon- 
junctival ecchymosis,  bulging  of  the  eyeballs,  etc. 

The  Middle  Fossa. — The  middle  fossa  of  the  skull  is  of  much 
surgical  importance.  It  lodges  the  temporo-sphenoidal  lobes.  It  is 
narrow  in  the  middle  and  widens  out  upon  either  side.  The  floor 
of  the  middle  fossa  corresponds  about  with  the  level  of  the  z3^goma  and 
is  limited  in  front  by  the  posterior  border  of  the  lesser  wing  of  the 
sphenoid  and  by  the  optic  groove;  behind  by  the  dorsum  epiphii  and 
the  upper  border  of  the  petrous  portion  of  the  temporal  bone.  The 
upper  border  of  the  petrous  portion  is  marked  by  a  groove  for  the 
superior  petrosal  sinus  and  gives  attachment  to  the  tentorium  eerebelli. 
The  floor  of  the  middle  fossa  consists  in  the  middle  line  of  the  upper 
surface  of  the  body  of  the  sphenoid,  presenting  in  •  front  the  optic 
groove,  at  either  end  of  which  is  the  optic  foramen;  behind  the  optic 
groove  is  the  sella  turcica,  a  deep  depression  which  lodges  the  pituitary 
body  and  which  is  bounded  behind  by  the  dorsum  epiphii.  Laterally 
the  floor  of  this  fossa  consists  of  the  upper  surface  of  the  great  wing 
of  the  sphenoid,  the  anterior  surface  of  the  petrous  portion  of  the 
temporal  and  a  part  of  the  scjuamous  portion  of  the  temporal.  The 
body  of  the  sphenoid  is  marked  uj)on  either  side  by  a  groove  which 
commences  behind  at  the  foramen  lacerum  medium  (carotid  foramen) 
and  terminates  in  front  at  the  optic  foramen.  This  lodges  the  cav- 
ernous sinus,  etc. 

The  foramen  lacerum  medium  is  formed  at  the  expense  of  the 
anterior  superior  surface  of  the  apex  of  the  petrous  portion  of  the 
temporal;  it  is  bounded  in  front  by  the  posterior  border  of  the 
great  wing  of  the  sphenoid  and  behind  by  the  apex  of  the  petrous 
portion;  through  this  opening  the  internal  carotid  artery  enters  the 
cranium.  Behind  and  external  to  this  foramen  the  antero-superior 
surface  of  the  petrous  portion  presents  a  depression  in  which  the 


SURGICAL  ANATOMY  OF  THE  HEAD. 


47 


Fig.  30.— Base  of  the  Skull  from  Within. 


48  •  HEAD  AND  FACE. 

Gasserian  ganglion  rests.  The  plate  of  bone  upon  which  the  ganglion 
rests  is  very  thin  and  forms  the  roof  of  the  canal,  which  is  traversed 
by  the  carotid  artery.  Anteriorly  in  close  proximity  to  the  ganglion 
and  its  three  trunks  is  the  cartilaginous  end  of  the  Eustachian  tube. 
In  front  of,  and  external  to,  the  foramen  lacerum  medium,  in  the  pos- 
terior part  of  the  great  wing  of  the  sphenoid,  there  is  a  large  open- 
ing, the  foramen  ovale.  As  its  name  indicates,  this  opening  is  oval 
in  shape,  its  long  diameter  being  directed  from  without  inward  and 
a  little  forward.  This  opening  is  seen  externally  upon  the  base  of  the 
skull  at  the  root  of  the  pterygoid  process,  external  to  the  external  pter- 
ygoid plate.  Through  this  opening  the  inferior  maxillary  or  third 
■division  of  the  fifth  nerve,  together  with  the  motor  root  of  the  fifth, 
•emerges  from  the  cranial  cavity.  Just  external  to  the  foramen  ovale 
and  a  little  behind  it,  in  the  apex  or  angle  of  the  gi'eat  wing  of  the 
sphenoid,  is  the  foramen  spinosum,  through  which  the  middle  menin- 
geal artery  enters  the  skull.  From  this  opening  a  groove  is  seen  run- 
ning outward,  marking  the  squamous  portion  of  the  temporal  near  its 
junction  with  the  petrous  portion;  this  groove  lodges  the  posterior 
Taranch  of  the  middle  meningeal  artery  and  is  continued  upward  upon 
the  side  of  the  skull  across  the  posterior  inferior  part  of  the  parietal 
iDone.  Commencing  at  or  near  the  foramen  spinosum  there  is  another 
groove,  which  runs  forward  and  outward  across  the  squamous  por- 
tion of  the  temporal  and  the  great  wing  of  the  sphenoid,  ascending 
upon  the  side  of  the  skull,  across  the  anterior  inferior  portion  of 
the  parietal  bone;  in  this  groove  rests  the  anterior  division  of  the 
middle  meningeal  artery.  The  groove  that  lodges  the  anterior  branch 
of  the  middle  meningeal  artery  is  very  often  quite  deep  with  sharp 
■edges,  or  it  may  be  converted  into  a  canal.  In  this  way  the  vessel  is 
gripped  very  tightly,  and  any  blow  or  violence  that  tends  to  shake 
or  displace  the  contents  of  the  cranium  is  likely  to  result  in  tearing 
of  this  vessel.  As  a  matter  of  fact  this  is  the  vessel  that  is  almost 
always  the  site  of  intracranial  hemorrhage  when  due  to  traumatism. 
About  one-half  inch  in  front  of,  and  a  little  internal  to,  the  foramen 
ovale  is  the  foramen  rotundum.  This  is  the  commencement  of  a 
short  canal  which  passes  obliquely  forward  through  the  great  wing 
■of  the  sphenoid  and  opens  into  the  spheno-maxillary  fossa  through 
the  upper  part  of  its  posterior  wall;  the  superior  maxillary  or  second 
division  of  the  fifth  nerve  passes  through  this  canal.  Toward  the 
front  of  the  middle  fossa  we  have  the  sphenoidal  fissure  opening 
into  the  orbit;  this  is  a  large  triangular  opening  between  the  free 


GASSERIAN  GANGLION,  ETC.  49 

border  of  the  great  wing  and  the  under  surface  of  the  lesser  wing  of 
the  sphenoid,  its  base  being  inward  toward  the  body  of  the  sphenoid. 
Through  this  fissure  pass  the  third,  the  fourth,  the  ophthahnic  or 
first  division  of  the  fifth  and  the  sixth  nerves,  the  ophthalmic  vein,  etc. 

In  the  outer  part  of  the  petrous  portion  of  the  temporal  bone 
is  lodged  the  hearing  apparatus — the  middle  ear  and  mastoid  antrum, 
and  the  internal  ear  and  auditory  nerve.  The  roof  of  the  middle 
ear  and  antrum,  tegmen  tympani.  is  very  thin,  and  infection  may 
readily  spread  from  these  cavities  into  the  cranial  cavity — to  the 
meninges   and   temporo-sphenoidal   lobe. 

Fracture  of  the  middle  fossa  of  the  skull  is  marked  by  the  escape 
of  blood  or  cerebro-spinal  fluid  from  the  ear,  or,  maybe,  into  the 
phar^Tis  through  the  Eustachian  tube. 

The  Gasserian  Ganglion,  etc. — The  Gasserian  ganglion  is 
frequently  the  object  of  surgical  intervention,  and  its  relationship  to 
important  adjacent  structures,  to  the  cavernous  sinus,  the  internal 
carotid  artery,  etc.,  is  of  the  greatest  interest. 

The  cavernous  sinus  is  a  wide,  loose,  thin-walled  canal  which  is 
situated  between  the  layers  of  the  dura  mater.  It  reaches  from  the 
apex  of  the  petrous  portion  of  the  temporal  bone  behind  to  the  inner 
end  of  the  sphenoidal  fissure  in  front,  being  lodged  in  the  cavernous 
groove  upon  the  side  of  the  body  of  the  sphenoid.  The  lumen  of 
the  cavernous  sinus  presents  a  peculiar  reticular  structure,  being 
broken  up  into  numerous  cellular  spaces  by  trabeculse  and  septa 
which  pass  in  various  directions.  Anteriorly  the  cavernous  sinus 
receives  the  ophthalmic  vein,  and  posteriorly  it  joins  with  both  petrosal 
sinuses  and  communicates  with  the  pterygoid  plexus  through  the 
veins  whidi  enter  the  skull  through  the  foramina  ovale,  spinosum, 
and  lacerum  medium.  The  external  border  of  the  cavernous  sinus 
corresponds  to  a  line  running  from  before  backward,  which  would 
just  skirt  the  inner  margin  of  the  foramen  rotundum. 

The  internal  carotid  artery  enters  the  cranium  through  the  fora- 
men lacerum  medium  and  passes  forward,  along  the  side  of  the  body 
of  the  sphenoid,  enveloped  by  the  cavernous  sinus,  the  sinus  being, 
as  it  were,  wrapped  entirely  around  the  artery.  (One  could  not  wound 
the  artery  in  this  situation  without  first  cutting  into  the  sinus.) 
Anteriorly,  at  the  inner  side  of  the  anterior  clinoid  process,  the  in- 
ternal carotid,  after  giving  ofE  its  ophthalmic  branch,  turns  upward 
and,  passing  through  an  opening  in  the  dura  mater,  divides  into  its  two 
terminal  branches,  the  anterior  and  middle  cerebral  arteries.     Along 

4 


50 


HEAD  AND  FACE. 


the  outer  side  of  the  artery,  and  therefore  also  inclosed  within  the 
cavernous  sinus,  runs  the  sixth  nerve.  In  the  outer  wall  of  the 
cavernous  sinus  and  intimately  united  to  it,  the  third,  the  fourth,  and 
the  ophthalmic  or  first  division  of  the  fifth  nerve  are  lodged;  these 
structures  cannot  be  separated  from  the  wall  of  the  sinus  without 


Fig.  31.— Middle  Fossa  showing  the  Position  of  the  Gasserian  Ganglion,  Three 
Divisions  of  the  Fifth  Nerve,  etc.  C,  cavernous  sinus;  GG,  Gasserian  ganglion; 
IP,  inferior  petrosal  sinus;  JV,  commencement  of  the  internal  jugular  vein; 
.S',  sigmoid  sinus;  8P,  superior  petrosal  sinus;  1,  2,  3,  first,  second,  and  third 
divisions  of  the  fifth  nerve.  The  intimate  relationship  of  the  first  division  of  the 
nerve  with  the  cavernous  sinus  is  indicated. 


tearing  it,  and  their  relation  to  each  other  is  in  the  order  given  both 
from  within  outward  and  from  above  downward. 

The  fifth  nerve  at  its  origin  appears  upon  the  side  of  the  pons 
Varolii,  and  consists  of  a  thick  sensory  and  a  small  motor  root;  these 
pass  forward  through  an  oval  slit  in  the  dura  mater  and  across  the 


GASSERIAX  GAXGLIOX,  ETC.  51 

upper  border  of  the  petrous  portion  of  the  temporal  bone,  near  its 
apex,  into  the  middle  fossa  of  the  skull.  As  the  roots  pass  over  the 
upper  border  of  the  petrous  portion,  they  lie  beneath  the  superior 
petrosal  sinus,  extradural:  i.e.,  between  the  dura  mater  and  the 
base  of  the  skull.  Upon  reaching  the  front  surface  of  the  petrous 
portion  of  the  temporal  bone  the  sensory  root  presents  a  swelling, 
the  Gasserian  ganglion.  The  motor  root  takes  no  part  in  the  forma- 
tion of  this  ganglion,  but  lies  underneath  it.  The  ganglion  rests  in 
the  depression  upon  the  front  surface  of  the  apex  of  the  petrous 
portion.  It  is  reddish  gray  in  color,  crescentic  or  semilunar  in  shape, 
the  anterior  convex  border  looking  foiT;\'ard,  downward,  and  outward. 
It  is  14  to  22  mm.  wide,  4  mm.  from  before  backward,  and  II/2  m™- 
in  thickness. 

Given  off  from  the  anterior  border  of  the  ganglion  are  the  three 
divisions  of  the  fifth  nerse.     Of  these,  the  first,  or  ophthalmic,  the 


€M    B 

Fig.  32. — Cross-section  through  Middle  Fossa  just  Anterior  to  Position  of 
the  Gasserian  Ganglion.  Shows  the  relation  of  the  cavernous  sinus  to  adjacent 
structures.  B,  bony  floor  of  middle  fossa;  CA,  internal  carotid  artery  inclosed 
within  the  trabeculated  cavernous  sinus;  Cil,  cavum  Meckelii;  DM,  dura 
mater  forms  periosteum  covering  floor  of  middle  fossa  and  roofs  over  the  cavum 
Meckelii;  3,  third  nerve;  4,  fourth  nerve;  5',  fiirst  division  of  fifth  nerve; 
5",  second  division  of  fifth  nerve;  5"',  third  division  of  fifth  nerve;  6,  sixth 
nerve;  the  third,  fourth,  and  first  division  of  the  fifth  nerve  are  incorporated  in 
the  wall  of  the  cavernous  sinus.  The  sixth  nerve  is  wholly  within  the  sinus. 
The  second  and  third  divisions  of  the  fifth  nerve  are  situated  within  the  cavum 
Meckelii. 

longest  and  thinnest  of  the  three,  is  the  most  internal  and  passes 
from  behind  forward  and  upward  along,  or  rather  in,  the  outer  wall 
of  the  cavernous  sinus,  entering  the  orbit  through  the  sphenoidal 
fissure.  On  account  of  its  intimate  relation  to  the  wall  of  the  sinus, 
any  attempt  to  separate  it  would  be  likely  to  tear  the  wall  of  the 
sinus;  it  is  in  close  relation  with  the  third  and  fourth  nerves,  the 
carotid  arter\',  and  the  sixth  nerve.  The  second,  or  superior  maxillary 
division  lies  external  to  the  preceding,  is  8  to  11  mm.  long,  and  passes 
forward,  entering  the  foramen  rotundum,  and  emerges  from  this 
canal  in  the  spbeno-maxillary  fossa.  This  branch  lies  close  to  the 
outer  edge  of  the  cavernous  sinus,  but  is  not  joined  to  it,  and  may 
be  readilv  removed  without  danger  to  the  sinus.     The  third,  or  in- 


52  HEAD  AND  FACE. 

fericr  maxillaiy,  division^,  the  most  external  of  the  three,  is  short 
and  thick,  and  passes  forward  and  outward,  leaving  the  skull  through 
the  foramen  ovale  in  company  with  the  motor  root.  The  motor  root 
winds  around  the  third  division  to  get  upon  its  outer  side,  the  two 
becoming  joined  just  after  their  exit  through  the  foramen  ovale. 
The  ganglion  rests  in  the  depression  already  described  upon  the  front 
surface  of  the  petrous  portion  of  the  temporal  bone.  The  motor 
root  of  the  nerve  takes  no  part  in  the  formation  of  the  ganglion,  but 
lies  beneath  it,  between  it  and  the  bone.  At  times  the  bone  is  absent 
in  this  location  and  under  such  circumstances  the  ganglion  will  be 
found  to  be  separated  from  the  carotid  artery  only  by  the  fibrous 
tissue  which  intervenes.  The  surface  of  bone  upon  which  the  ganglion 
and  its  three  divisions  rest  is  covered  by  the  periosteum.  The  ganglion 
and  its  divisions,  as  already  mentioned,  are  placed  extradural :  i.e., 
between  the  dura  mater  and  the  base  of  the  skull;  the  dura  roofs 
them  over,  and  is  attached  to  the  margins  of  the  depression  in  which 
the  ganglion  rests  and  to  the  floor  of  the  middle  fossa  of  the  skull, 
along  the  inner  margin  of  the  second  division  and  along  the  outer 
margin  of  the  third  division;  so  that  not  only  the  ganglion,  but  its 
second  and  third  divisions  as  well,  are  thus  roofed  in.  This  space, 
in  which  the  ganglion  and  its  second  and  third  divisions  are  thus 
inclosed,  is  called  the  cavum  Meckelii.  Beyond  the  ganglion  and  its 
divisions  the  dura  is,  as  elsewhere,  closely  applied  to  the  surface  of  the 
bone.  The  ganglion  and  its  divisions  are  but  loosely  attached  to  the 
periosteum  which  covers  the  surface  of  the  bone  upon  which  they  rest 
(floor  of  cavum  Meckelii)  and  to  the  dura  mater  which  covers  them 
and  forms  the  roof  of  the  cavum  Meckelii. 

The  cavum  Meckelii  is  really  a  space  in  the  floor  of  the  middle 
fossa  of  the  skull  between  the  bone  and  the  non-attached  dura,  which' 
lodges  the  ganglion  and  its  second  and  third  divisions. 

The  Gasserian  ganglion  is  in  relation,  internally,  with  the  carotid 
artery  and  cavernous  sinus.  Behind  the  ganglion  is  the  superior 
petrosal  sinus  underneath  which  the  roots  of  the  nerve  must  pass 
in  order  to  reach  the  ganglion  as  it  rests  upon  the  front  surface  of 
the  petrous  portion.  The  superior  petrosal  sinus  is  contained  in 
the  edge  of  the  tentorium  cerebelli,  which  is  attached  to  the  superior 
border  of  the  petrous  portion. 

The  middle  meningeal  artery  enters  the  skull  through  the  fora- 
men spinosum  just  external  to,  and  a  little  behind,  the  foramen 
ovale  (through  which  the  third  division  passes  out  of  the  skull)  and 


DURA  MATER.  53 

would  therefore  be  met  with  in  approaching  these  structures  through 
an  opening  in  the  side  of  the  skull. 

The  Posterior  Fossa. — This  is  the  deepest  of  the  three  fossae. 
It  contains  the  cerebellum,  pons,  and  medulla.  It  is  formed,  for  the 
most  part,  of  the  occipital  bone,  the  petrous  and  mastoid  portions 
of  the  temporal  bone  taking  part  in  its  formation  anteriorly  and 
laterally.  About  the  middle  it  presents  a  large  opening — the  fora- 
men magnum — for  the  passage  of  the  cord.  In  front  of  the  foramen 
magnum  is  the  smooth,  shelving,  grooved  basilar  process  which  sup- 
ports the  medulla  and  pons.  On  either  side  of  the  foramen  magnum 
is  the  foramen  lacerum  posterius.  Xear  the  foramen  lacerum  pos- 
terius  the  lateral  sinus  is  joined  Ijy  the  inferior  petrosal  sinus  to 
form  the  internal  Jugailar  vein,  which  leaves  the  skull  through  the 
foramen  lacerum  posterius.  The  petrous  portion  presents  the  orifice 
of  the  auditory  canal  through  which  the  facial  and  auditory  nerves 
enter  the  bone.  The  posterior  fossa  is  divided  in  two  halves  by  the 
internal  occipital  crest,  which  occupies  the  middle  line  passing  from 
the  posterior  margin  of  the  foramen  magnum  to  the  internal  occipital 
protuberance.  It  gives  attachment  to  the  falx  cerebelli  and  lodges 
the  occipital  sinus.  The  broad  grooves  for  the  lateral  sinuses  are 
seen  passing  outward  on  either  side  from  the  internal  occipital  pro- 
tuberance. The  groove  is  continued  from  the  occipital  bone  on  to 
the  lower  posterior  angle  of  the  parietal,  where  it  bends  rather  sharply 
downward,  "S"  fashion,  upon  the  mastoid  portion  of  the  temporal, 
then  it  curves  forward  again  on  to  the  occipital  bone,  and  ends  at 
the  foramen  lacerum  posterius.  Upon  the  mastoid  portion  of  the 
groove  for  the  lateral  sinus  is  seen  an  opening  for  the  passage  of 
a  small  vein  from  the  occipital  vein,  from  without  to  the  lateral 
(sigmoid)    sinus. 

The  Dura  Mater  is  a  strong,  tough,  non-elastic,  fibrous  mem- 
brane which  lines  the  inner  surface  of  the  skull.  It  is  described  as  one 
of  the  coverings  of  the  brain,  but  should,  in  fact,  be  considered  as 
an  appendage  of  the  skull  in  contra-distinction  to  the  pia  mater,  or, 
better,  the  pia-arachnoid,  Avhich  is  essentially  an  appendage  of  the 
brain.  The  dura  mater  is  closely  attached  to  the  bones,  more  in- 
timately to  those  of  the  base  than  those  of  the  vault,  forming  their 
periosteum;  but  it  may  be  detached  from  the  bones  without  much 
difficulty.  It  supports  the  intracranial  arteries,  veins,  and  venous 
sinuses,  and,  when  detached  from  the  surface  of  the  bones,  carries 
these  vessels  with  it. 


54  HEAD  AND  FACE. 

Anteriorly,  ramifying  in  the  dura  mater,  is  the  anterior  me- 
ningeal artery,  which  is  a  branch  of  the  ethmoid.  Corresponding 
to  the  middle  fossa  of  the  skull  and  the  temporal  region,  the  middle 
meningeal  artery  is  found.  This  is  a  branch  of  considerable  size,  and 
is  of  much  surgical  importance;  it  is  derived  from  the  internal  max- 
•illary  and  enters  the  skull  through  the  foramen  spinosum  in  the  base 
of  the  skull.  Behind  are  the  posterior  meningeal  branches  which 
are  derived  from  the  occipital  and  the  vertebral. 

The  dura  mater  gives  off  three  strong  processes,  the  falx  cerebri 
and  falx  cerebelli,  and  the  tentorium  cerebelli.  The  falx  cerebri 
occupies  the  middle  line,  being  attached  along  the  line  of  the  sagittal 
suture  and  serves  to  separate  the  two  hemispheres  of  the  cerebrum. 
The  falx  cerebelli  is  attached  to  the  occipital  bone  along  the  line  of 
the  internal  occipital  crest,  and  separates  the  two  halves  of  the 
cerebellum.  The  tentorium  cerebelli  is  attached  to  the  prominent 
bony  margins  of  the  posterior  fossa,  to  the  horizontal  portion  of  the 
groove  for  the  lateral  sinus  as  far  as  the  point  where  the  groove 
strikes  the  angle  of  the  parietal  bone,  and  from  this  point  to  the 
prominent  upper  border  of  the  petrous  portion  of  the  temporal  bone. 
The  tentorium  presents  a  large,  rounded  opening  anteriorly  to  ac- 
commodate the  mesencephalon — corpora  quadrigemina  and  crura  cer- 
ebri— that  portion  of  the  brain  which  connects  the  cerebrum  with  the 
parts  that  are  lodged  in  the  posterior  fossa.  The  posterior  fossa  is 
partly  roofed  in  by  the  tentorium  cerebelli,  the  posterior  lobes  of  the 
cerebrum  resting  upon  the  tentorium. 

The  Venous  Sinuses  of  the  Dura  Mateu. — There  are  a  num- 
ber of  large  venous  sinuses  which  are  situated  between  the  layers  of 
the  dura,  and  which  groove  the  surface  of  the  bones  along  their 
course. 

The  Superior  Longitudinal  Sinus  runs  from  before  back- 
ward along  the  line  of  the  sagittal  suture,  a  little  more  to  the  right 
of  the  middle  line,  from  the  foramen  caecum  in  front  to  the  internal 
occipital  protuberance  behind,  where  it  becomes  the  right  lateral 
sinus.  It  is  situated  between  the  layers  of  the  falx  cerebri,  which 
are  separated  along  the  line  of  their  attachment  to  the  bone  in  order 
to  accommodate  the  sinus.  The  sinus  is  wedge-shaped  on  section, 
and  increases  in  width  from  before  back,  from  i/4  inch  in  width  in 
front  to  %  inch  in  width  behind.  In  the  middle  of  its  course  the 
longitudinal  sinus  gives  off  a  number  of  processes,  the  parasinoidal 
sinuses  or  lacunse,  that  extend  outward  between-  the  layers  of  the 


DURA  MATER.  55 

dura  over  the  surface  of  the  hemispheres  for  a  distance  of  IY2  to  2V2 
em.;  therefore  within  this  distance  of  the  sagittal  line  caution  must 
be  exercised  to  thoroughly  separate  the  dura  before  gouging  away 
the  bone  so  as  not  to  tear  these  lateral  extensions  of  the  longitudinal 
sinus.  The  superior  cerebral  veins  terminate  in  the  longitudinal 
sinus  and  parasinoidal  lacunar.  The  anterior  branches  pass  straight 
inward,  the  posterior  passing  obliquely  forward  and  inward.  They 
unite  with  branches  from  the  inner  surface  of  the  hemisphere  before 
entering  the  sinus.  These  veins  have  to  pass  from  the  arachnoid 
layer  across  the  sidadural  space  to  reach  the  sinuses,  and  may  thus 
be  torn  by  overlapping  of  the  bones  (parietals)  in  moulding  of  the 
head  in  difficult  labor,  with  resulting  hemorrhage  and  subsequent 
paralysis,  idiocy,  etc.  The  longitudinal  sinus  communicates  with  the 
veins  of  the  scalp  and  venous  channels  in  the  diploe  through  a  vari- 
able number  of  emissaries  that  pass  through  foramina  in  the  bones. 
In  detaching  the  dura  from  the  bone  at  these  places  these  veins  are 
usually  torn  and  severe  hemorrhage  may  result.  Into  the  parasi- 
noidal sinuses,  lacunte,  and  into  the  longitudinal  sinus  the  Pacchionian 
bodies  project,  they  being  suspended  and  bathed,  as  it  were,  in  the 
blood-stream  of  the  sinus. 

The  Inferior  Longitudinal  Sinus  is  situated  between  the 
layers  of  the  falx  cerebri  along  its  free  border.  It  terminates  pos- 
teriorly by  joining  with  the  vena  magna  Galeni,  which  drains  the  deep 
parts  of  the  cerebrum,  to  form  the  straight  sinus. 

The  Straight  Sinus  passes  backward  in  the  middle  line  be- 
tween the  layers  of  the  dura  in  the  recess  formed  by  the  junction  of 
the  falx  cerebri  with  the  tentorium  cerebelli.  It  terminates  usually 
in  the  left  lateral  sinus. 

The  Lateral  Sinuses  are  important  surgically.  They  are 
lodged  in  the  grooves  on  the  occipital  bones  between  the  layers  of 
the  tentorium  cerebelli,  which  are  attached  to  the  margins  of  the 
grooves.  The  right  is  usually  the  direct  continuation  of  the  superior 
longitudinal  sinus.  From  the  center  of  the  occipital  bone  that  of 
either  side  passes  transversely  outward,  gi-ooving  the  occipital  bone 
and  the  posteror  inferior  corner  of  the  parietal.  Here  the  lateral 
sinus  is  joined  by  the  superior  petrosal,  which  runs  along  the  superior 
border  of  the  petrous  portion  of  the  temporal  bone  between  the 
layers  of  the  attached  tentorium  cerebelli.  Tlie  sinus  then  curves 
downward,  grooving  the  inner  surface  of  the  mastoid,  and  from  this 
bone  is  continued  again  over  on  to  the  occipital,  crossing  the  upper 


56  HEAD  AND  FACE. 

surface  of  the  jugular  process  of  this  bone,  to  join  Avith  the  inferior 
petrosal  sinus  to  form  the  internal  jugular  vein.  The  course  of  the 
transverse  portion  of  the  lateral  sinus  corresponds  to  a  line  drawn 
from  the  external  occipital  protuberance  to  the  upper  margin  of  the 
external  auditory  meatus.  That  portion  of  the  lateral  sinus  that 
corresponds  to  the  mastoid  portion  of  the  temporal  bone  is  called 
the  sigmoid  sinus.  It  frequently  becomes  involved  in  inflammatory 
processes  that  affect  the  middle  ear  and  mastoid  antrum. 

The  Cavernous  Sinus  is  lodged  in  the  groove  upon  the  side  of 
the  body  of  the  sphenoid  bone.  The  internal  carotid  artery  passes 
from  behind  forward,  from  the  orifice  of  the  carotid  canal  in  the 
apex  of  the  petrous  portion  of  the  temporal  bone,  where  the  artery 
enters  the  cranium,  to  the  point  where  it  divides  into  its  terminal 
branches.  This  part  of  the  internal  carotid  artery  is  enveloped  by 
the  cavernous  sinus,  the  wall  of  the  sinus  being,  as  it  were,  wrapped 
around  the  artery.  The  sixth  nerve  is  also  inclosed  entirely  within 
the  sinus,  lying  below  and  to  the  outer  side  of  the  artery.  The  third, 
fourth,  and  the  ophthalmic  division  of  the  fifth  nerve  are  located 
in  the  outer  wall  of  the  cavernous  sinus,  but  are  not  contained  within 
its  lumen  as  are  the  internal  carotid  artery  and  the  sixth  nerve.  ( See 
Fig.  32.)  The  sinus  may  be  torn  in  fracture  of  the  middle  fossa. 
Thrombosis  of  the  cavernous  sinus  is  accompanied  by  extensive  sub- 
conjunctival hemorrhage,  marked  bulging  of  the  eyeball,  hemorrhage 
into  the  retina,  etc. 

The  blood-pressure  within  the  sinuses  is  low,  and  hemorrhage 
during  the  course  of  operation  is  readily  controlled  by  packing  with 
strip  gauze. 

The  Brain  is  a  semisolid  mass  which  is  contained  in  a  solid,  non- 
yielding,  bony  case — the  skull.  The  skull  offers  a  considerable  degree 
of  protection  to  the  vital  organs  contained  within.  The  brain,  with 
its  peculiar  covering,  pia-arachnoid,  occupies  completely  the  space 
within  the  skull,  so  completely  that  the  impressions  of  the  convolu- 
tions of  the  brain  and  arteries  in  the  dura  are  evident  upon  the 
surface  of  the  bones.  In  this  respect  the  brain  differs  from  the  cord, 
which  does  not  completely  fill  the  vertebral  canal.  Ample  space 
exists  between  the  cord  enveloped  in  its  pia-arachnoid  and  the  dura 
and  between  the  dura  and  the  bony  canal.  The  volume  (bulk)  of 
the  brain  increases  or  diminishes  according  to  the  quantity  of  blood 
that  it  contains,  and  when  exposed  is  seen  to  pulsate  with  each  heart 
beat  and  with  each  respiration.     Any  addition  to  the  normal  con- 


BRAIN. 


57 


tents  of  the  iinyieldirig,  bony,  cranial  cavity,  such  as  extraversated 
blood,  tumor,  abscess,  etc.,  causes  increase  of  the  intracranial  pressure, 
which  is  i^romptly  manifested  by  characteristic  general  symptoms, 
such  as  headache,  dizziness,  vomiting,  impaired  cerebration,  etc.,  and 
by  certain  localizing  symptoms  if  certain  definite  parts  of  the  brain 
are  affected.     In  the  young  child  this  increase  of  pressure  may  be 


Hind-brain 


Fig.  33. — Schema  showing  Parts  Derived  from  the  Three  Original  Brain 
Vesicles.  CQ',  CQ",  corpora  quadrigemina,  superior  and  inferior;  S.P.,  M.P., 
I. P.,  superior,  middle,  and  inferior  peduncles  of  the  cerebellum. 

compensated  for  by  a  spreading  apart  of  the  bones,  and  in  the  adult 
to  a  limited  extent  by  displacement  of  the  cerebro-spinal  fluid.  The 
interior  of  the  brain  is  hollowed  out  by  a  system  of  ventricles  which 
communicate  with  each  other,  and  they  in  turn  communicate  with 
the  .subarachnoid  space  through  three  openings  of  variable  size  in 
the  membranous  roof  of  the  fourth  ventricle.  The  ventricles  also 
communicate  with  the  subarachnoid  space,  through  a  slit-like  opening 
in  the  anterior  part  of  the  descending  horn  of  each  lateral  ventricle. 


58 


HEAD  AND  FACE. 


The  brain  may  be  considered  as  consisting  of  three  portions : 
the  cerebrum  developed  from  the  fore-brain  vesicle;  the  cerebellum, 
pons  Varolii,  and  medulla  derived  from  the  hind-brain  vesicle,  and 
the  parts  that  connect  the  two,  the  crura  cerebri,  corpora  quadri- 
^emina,  which  are  developed  from  the  mid-brain  vesicle. 

The  two  cerebral  hemispheres  are  separated  from  each  other 
by  a  deep,  narrow  fissure,  the  longitudinal  fissure.  This  fissure  re- 
•ceives  the  falx  cerebri.  Each  hemisphere  presents  three  surfaces : 
an  internal,  an  inferior,  and  an  external.     The  external  surface  of 


^^Ol-A^NDO 


Fig.  34. — External  Surface  of  the  Cerebrum.  O.S.,  genu  superior,  fissure  of 
Rolando;  G.I.,  genu  inferior,  fissure  of  Rolando;  F.S.^,  anterior  ascending  arm 
of  fissure  of  Sylvius;  F.8.^,  anterior  horizontal  arm  of  Assure  of  Sylvius. 


the  hemisphere  presents  several  well-marked  fissures  which  serv^e  to 
divide  it  into  its  several  lobes,  and  are  of  guiding  importance  to 
the  surgeon  for  operative  purposes.  The  three  main  fissures  are : 
the  fissure  of  Eolando,  the  fissure  of  Sylvius,  and  the  parieto-occipital 
fissure.  The  fissure  of  Rolando  separates  the  frontal  lobe  from  the 
parietal.  It  commences  above  a  little  behind  the  mid-point  of  the 
inner  border  of  the  cerebrum,  is  directed  downward  and  forward, 
and  terminates  just  above  the  lower  end  of  the  fissure  of  Sylvius. 
It  forms  an  angle  of  67°  to  70°  with  the  inner  border  of  the  cerebrum. 
This  angle  varies  within  a  range  of  4°  or  5°  in  different  cases.  The 
line  described  by  the  fissure  of  Eolando  is  not  straight,  but  curved 


BRAIX. 


59 


with  the  concavity  looking  forward  and  corresponding  roughly  to 
its  middle  third.  The  points  limiting  this  curved  portion  of  the 
fissure  of  Rolando  are  called  the  genu  superior  and  the  genu  inferior. 
The  fissure  of  Sylvius  is  the  most  conspicuous  and  striking.  It 
corresponds  to  the  upper  border  of  the  anterior  portion  of  the  temporo- 
sphenoidal  lobe.  It  spreads  out  in  three  radiating  arms,  a  posterior 
horizontal  which  passes  backward,  separating  the  temporo-sphenoidal 


FIS.  PAR  I  ETC- OCC I  P. 


Fig.  35.— Surface    of    Cerebrum    from    above.      O.S.,    genu    superior,    fissure    of 
Rolando;  G.I.,  genu  inferior,  fissure  of  Rolando. 

lobe  from  the  parietal,  and  which  is  really  the  continuation  of  the 
fissure  proper;  an  anterior  ascending,  which  passes  upward  into  the 
third,  inferior,  frontal  convolution,  and  an  anterior  horizontal,  which 
passes  forward  into  the  same  convolution. 

The  parieto-occipital  fissure,  as  seen  upon  the  external  surface 
of  the  cerebrum,  is  little  more  than  a  notch  upon  the  inner  border 
of  the  cerebrum,  and  serves  to  mark  the  boundary  line  between  the 
parietal  and  occipital  lobes.  The  parieto-occipital  fissure  is  well 
marked  upon  the  inner  surface  of  the  hemisphere. 


60 


HEAD  AND  FACE. 


If  the  edges  of  the  fissure  of  Sylvius  are  separated,  that  portion 
of  the  cerebrum  called  the  island  of  Eeil  is  exposed  to  view.  This 
area  is  not  covered  in  the  foetus,  but  becomes  covered  over  as  a  re- 
sult of  the  overgrowing  of  the  frontal,  parietal,  and  temporo-  sphe- 
noidal lobes  during  the  course  of  their  development. 

The  convolutions  immediately  anterior  and  posterior  to  the  fissure 
of  Eolando  are  called  the  gyrus  prgecentralis  and  the  gyrus  post- 
centralis.  The  motor  area  corresponds  to  the  anterior  of  these  two 
convolutions,  extending  forward  on  to  the  adjacent  parts  of  the  frontal 


i^l-Afvr 


Fig.  36. — Showing  the  Motor  Area;  Sensory  Area  (cutaneous  and  muscular 
sense);  Stereognosis;  Hearing;  Speech  (Speech  Expression  and  Speech  Under- 
standing,  Vocal  and  V^^ritten);  Vision. 


convolutions.  The  area  for  the  arm  corresponds  roughly  to  the  mid- 
dle third,  to  that  portion  of  the  convolution  which  lies  anterior  to 
the  concave  part  of  the  fissure  of  Eolando  between  the  genu  sujDerior 
and  the  genu  inferior;  the  portion  for  movements  of  the  leg  and 
trunk  above  this  area  and  for  movement  of  muscles  of  face,  tongue, 
etc.,  below  this  area. 

The  third  inferior  frontal  convolution  on  the  left  side  corresponds 
to  the  center  for  motor  speech — 'Broca's  convolution.  The  areas  con- 
cerned in  other  known  centers  are  shown  in  the  picture  from  Krause. 

The  internal  surface  of  the  cerebrum  is  flat,  presents  several 
fissures,  and  is  separated  from  that  of  the  opposite  hemisphere  by 
the  falx  cerebri. 


BRAIN. 


61 


The  inferior  surface — base  of  the  brain — rests  in  the  anterior 
and  the  middle  foss?e,  the  posterior  portion  being  supported  upon 
the  tentorium  cerebelli,  which  separates  it  from  the  cerebellum. 

The  cerebellum  is  lodged  in  the  posterior  fossa,  which  it  occupies 
in  common  with  the  pons  and  medulla.  The  cerebellum  consists  of 
two  hemispheres  joined  together  in  the  middle  hx  a  rather  constricted 
portion  called  the  vermis.  The  two  hemispheres  are  divided  up  into 
a  number  of  lobes  by  fissures,  etc. 

The  Pia  Mater. — The  brain  is  inclosed  within  its  own  peculiar 
membrane :    the  pia  mater.     This  is   a   connective  tissue  membrane 


Pig.  37.— Internal   Surface  of  the  Cerebrum. 


which  serves  to  support  the  vessels  which  supply  the  In-aiu,  and  con- 
tains within  its  meshes  the  cerebro-spinal  fluid.  It  acts  like  a  water 
cushion^  preserving  the  blood-vessels  from  pressure,  and  also  permits 
intracranial  tumors,  etc.,  to  acquire  an  appreciable  thickness  before 
they  begin  to  cause  pressure  symptoms.  The  brain  can  accommodate 
itself  to  slow-growing  tumors  until  they  reach  a  considerable  size 
by  crowding  out  the  cerebro-spinal  fluid.  The  pia  mater  is  not  a 
simple  flat  membrane,  but  is  really  made  up  of  two  layers  joined 
together  by  septa  which  divide  it  up  into  a  mesh-work  of  cellular 
spaces  within  which  is  contained  the  cerebro-spinal  fluid.  It  has 
been  compared  to  a  water-soaked  connective  tissue  with  a  superficial 
surface,  which  is  described  as  the  arachnoid,  and  a  deep  surface  which 
is  applied  directly  to  the  surface  of  the  brain — the  pia  mater  proper. 


63 


HEAD  AND  FACE. 


The  space  between  these  two  la3'ers  is  called  the  subarachnoid  space. 
The  pia  mater  or,  better  called,  the  pia-arachnoid,  has  no  connec- 
tion whatever  with  the  dura  mater;  so  that  between  the  inner  surface 
of  the  dura  and  the  external  surface  of  the  pia-arachnoid  there  is 
a  narrow  free  space,  or  crevice,  which  contains  a  minute  quantity  of 
fluid.     This  is  called  the  subdural  space.     Collections  of  blood  may 


Fig.  38. — Under  Surface  of  the  Cerebrum. 

be  found  in  the  subdural  space,  especially  in  connection  with  frac- 
ture of  the  base  of  the  skull.  The  dura  is  more  firmly  attached  to 
the  bones  of  the  base,  and  is  therefore  more  apt  to  tear  when  this 
part  of  the  skull  is  fractured,  and  thus  extra vasated  blood  is  allowed 
to  enter  the  subdural  space. 

As  already  mentioned,  the  pia  mater  may  be  described  as  con- 
sisting of  two  layers,  the  arachnoid  layer  and  the  pia  mater  proper. 
The  superficial  layer  is  called  the  arachnoid  and  the  deeper  layer, 
that  which  is  applied  directly  to  the  surface  of  the  brain,  is  called 
the  pia  mater.     This  latter  layer  is  intimately  adherent  to  the  sur- 


BRAIN. 


65 


face  of  the  brain,  it  clips  down  into  all  the  sulci  between  the  con- 
volutions, and  a  process  is  projected  forward  into  the  transverse  fis- 
sure of  the  brain  as  the  velum  interpositum,  between  tlie  body  of  the 
fornix  above  and  epithelial  roof  of  the  third  ventricle  below.  The 
venae  Galeni  emerge  posteriorly  from  between  the  two  layers  of  the 
velum  interpositum,  where  they  join  to  form  the  vena  magna  Galeni^ 
which  is  continued  into  the  straight  sinus.  The  pia  accompanies 
the  small  vessels  that  enter  the  cortex  for  a  short  distance  and  it 
cannot  be  detached  from  the  surface  of  the  brain  without  causing 
small  lacerations  and  hemorrhages  corresponding  to  the  points  where 


Skin 
Subcutaneous  connective  tissue 
Aponeurosis  occip.  front,  muscle  — -' 
L,ayer  of  loose  connective  tissue  '^'^fi 
Pericranium      ^i^i 

Bone 
Dura  mater 
Subtlural  space  ^^  . 
Pia-araehnoid  membrane  (ariich-     ^^  f 
noid  aud  pia  mater  proper.)              l| 
Gray  matter    X" 


White  matter 
PB,  Pacchionian  bodies 


Falx  cerebri 
Fig.  39.— Section   through    Scalp,    SkuU,   Brain,   etc. 

the  blood-vessels  penetrate.  The  space  between  the  two  layers  of  the 
pia  mater,  between  the  arachnoid  and  the  pia  mater  layer  proper, 
is  called  the  subarachnoid  space.  It  contains  the  cerebro-spinal  fluid 
and  supports  the  blood-vessels  that  supply  the  brain.  These  vessels 
ramify  in  the  subarachnoid  space,  between  the  two  layers  of  the  pia 
mater,  between  the  arachnoid  la^^r  and  the  pia  mater  proper. 

The  subarachnoid  space  is  not  a  free  space,  but  is  broken  up 
into  a  number  of  cellular  spaces  by  a  system  of  trabecuhp  that  extend 
between  the  two  layers.  All  these  spaces  communicate  freely  with 
one  another  aud  ■u'ith  the  ventricular  system  through  several  well- 
defined  openings  in  the  tela  choroidea.  Three  of  these  openings  are 
found  in  the  membranous  roof  of  the  fourth  ventricle :  one,  the 
foramen  of  Majendi.  in  the  middle  line  near  the  lower  angle,  and  two 
others,  one  in  each  lateral  recess.     Still  two  other  communications 


64  HEAD  AND  FACE. 

exist  between  the  ventricles  and  the  subarachnoid  space,  one  in  the 
anterior  extremity  of  the  descending  liorn  of  each  lateral  ventricle. 
Thus  free  communication  exists  between  the  ventricles  and  the  sub- 
arachnoid space.  Where  the  j)ia  covers  a  convolution  the  two  surfaces 
or  layers,  arachnoid  and  pia  proper,  are  close  together,  but  where 
the  pia  bridges  over  a  sulcus  the  layers  are  farther  apart  owing  to 
the  dipping  of  the  jDia  layer  proper  down  into  the  bottom  of  the 
sulcus.  Corresponding  to  certain  parts  of  the  base  of  the  brain 
the  two  layers  of  the  pia  mater  are  very  widely  separated,  forming 
water  cushions  and  spaces  of  considerable  size;  these  spaces  are  called 
cisterns  subarachnoidales.  Of  the  cisterns  the  largest  is  the  cisterna 
magna.  This  is  found  in  the  wide  interval  between  the  inferior 
surface  of  the  cerebellum  and  the  fourth  ventricle.  The  cisterna 
pontis  is  continuous  with  the  anterior  part  of  the  arachnoid  space 
of  the  cord;  it  is  situated  between  the  medulla  and  pons  and  the 
basilar  j)rocess  of  the  occipital  bone.  It  is  continuous  around  the  sides 
of  the  medulla  with  the  cisterna  magna,  so  that  this  part  of  the  brain 
is  completely  surrounded  by  a  wide  subarachnoid  space  like  a  water 
cushion.  The  basilar  artery  ascends  through  this  space,  resting  upon, 
the  basilar  process  of  the  occipital  bone.  From  the  upper  border  of 
the  pons  the  cisterna  pontis  is  continuous  anteriorly  with  the  cisterna 
basalis  or  interpeduncularis.  The  cisterna  basalis  tills  in  the  space 
between  the  temporo-sphenoidal  lobes,  gives  off  a  process  on  either 
side  which  reaches  into  the  Sylvian  fissure,  and  is  continued  forward 
into  a  space  anterior  to  the  optic  chiasma  and  thence  into  the  subarach- 
noid space  above  the  corpus  caPosum  in  the  great  longitudinal  fissure. 
In  this  space,  the  cisterna  basalis,  are  contained  the  arteries  that 
form  the  circle  of  Willis  and  the  nerve-roots  that  arise  from  the 
corresponding  portion  of  the  brain,  the  optic  tracts,  and  the  com- 
mencement of  the  two  terminal  branches  of  the  internal  carotid  artery, 
the  anterior  and  middle  cerebral.  That  portion  of  the  arachnoid 
space  which  lies  anterior  to  the  ■  inf undibulum  is  called  the  cisterna 
chiasmatis.  Processes  of  the  arachnoid  are  prolonged  for  a  short 
distance  upon  all  the  nerve-roots. 

Pacchionian-  Bodies. — These  are  appendages  of  the  arachnoid. 
They  consist  of  a  number  of  tuft-like  processes  arranged  along  the 
course  of  the  superior  longitudinal  sinus  on  either  side  of  the  middle 
line,  and  in  fewer  numbers  along  the  course  of  the  lateral,  straight 
sinuses,  etc.  These  processes  grow  from  the  arachnoid,  and  as  they 
grow  they  project  into  the  lumen  of  the  sinuses  and  the  parasinoidal 


CRANIO-CEREBRAL  TOPOGRAPHY. 


60 


lacuna?,  so  that  they  float  in  and  are  hathed  in  the  blood-stream.  They 
are  separated  from  the  blood  by  a  very  much  attenuated  layer  of 
dural  endothelium,  which  covers  them.  The  Pacchionian  bodies  are 
not  well  developed  in  children.  They  become  better  developed  as 
age  advances.  When  the  blood-pressure  is  low  in  the  sinuses  the 
cerebro-spinal  fluid  may  exude  from  the  subarachnoid  space  through 
the  Pacchionian  bodies  into  the  blood-stream.  Their  function  may 
thus  be  to  balance  the  pressure  between  the  cerebro-spinal  fluid 
and  the  blood  in  the  dural  sinuses. 


Fig.  40. — Chiene's   Schema   to   Locate   the   Fissure  of   Rolando,    etc. 

Cranio-cerebral  Topog*raphy. — In  order  to  expose  certain  definite 
parts  of  the  brain  and  in  so  doing  to  avoid  venous  sinuses,  meningeal 
arteries,  etc.,  it  is  necessary  to  study  the  relations  that  exist  be- 
tween certain  constant  markings  upon  the  brain,  grooves  upon  the 
inner  surface  of  the  skull,  etc.,  and  certain  fixed  points  that  may 
be  readily  determined  upon  the  exterior  of  the  skull  or  upon  the 
scalp.  The  important  bony  landmarks  have  been  described  and,  tak- 
ing these  as  guides,  certain  lines  and  angles  are  marked  upon  the  skull 
(scalp)  to  indicate  the  position  of  various  parts  of  the  brain,  venous 
sinuses,  arteries,  etc. 

There  are  a  number  of  methods  employed :  Chiene's,  Kronlein's, 
Ivocher's. 


66 


HEAD  AXD  FACE. 


Chiexe's  Method. — According  to  Cliiene  a  line  is  drawn  from 
the  glabella,  G,  to  the  external  occipital  protuberance,  0.  This  is 
called  the  sagittal  line,  and  upon  this  the  following  points  are  found : — 

1.  Mid-point,  M 

2.  Three-quarter  point,  T. 

3.  Seven-eighth  point,  S. 

In  addition  to  these  the  external  angular  process,  E,  is  located  and 
the  preauricular  point,  P,  corresponding  to  the  upper  surface  of  the 
root  of  the  zygoma,  just  above  and  in  front  of  the  external  auditory 
meatus. 

A  line  is  drawn  from  E  to  P,  and  other  lines  from  E  to  T  and 
from  P  to  *S'.     Find  the  mid-point  of  E-P  and  of  PS  at  N  and  R, 


SAGITTAL    LINE 


Fig.   41. — Rolandic  Angle. 

and  draw  lines  from  21  to  N  and  from  M  to  R.    Bisect  the  line  A-B 
at  C  and  draw  the  line  C-D  parallel  with  A-M. 

The  line  C-D  is  called  the  postcentral  line.  It  corresponds  to 
the  position  of  the  superior  and  inferior  postcentral  sulci.  The  line 
M-A  is  called  the  precentral  line.  It  corresponds  to  the  sulci  prae- 
centralis  superior  and  inferior.  Divide  the  line  M-A  in  thirds,  K-L, 
and  we  have  thus  indicated  the  position  of  the  superior  and  inferior 
frontal  sulci.  The  line  E-T  is  called  the  Sylvian  line.  It  crosses 
the  precentral  line  at  the  point  A,  which  corresponds  to  the  pterion 
and  to  the  Sylvian  jDoint,  and  the  anterior  branch  of  the  middle  me- 
ningeal artery.  A-C  corresponds  to  the  posterior,  horizontal  limb  of 
the  Sylvian  fissure,  which  terminates  behind  in  the  triangle  H-B-C. 
The  point  where  the  Sylvian  line  E-T  strikes  the  sagittal  line,  T, 
marks  the  location  of  the  parieto-occipital  fissure.  A  line  drawn  from 
T  to  R  and  from  R  to  0  marks  a  triangle  that  corresponds  to  the 
external  surface  of  the  occipital  lobe.     The  line  drawn  from  i^  to  0 


CRANIOCEREBRAL  TOPOGRAPHY. 


67 


corresponds  to  the  attachment  of  the  tentorium  and  to  the  upper 
margin  of  the  h^teral  sinus.  The  *space  included  between  the  pre- 
central  line  A-M  and  the  postcentral  line  C-D  corresponds  to  the 
Eolandic  area,  and  includes  the  gyrus  centralis  anterior  and  the  gvrus 
centralis  posterior,  which  are  separated  from  each  other  by  the  fissure 
of  Eolando — sulcus  centralis. 


Fig.  42.— Kronlein's  Schema,  to  Locate  the  Fissure  of  Rolando,  etc.  Ai,  A-, 
the  horizontal  lines;  B^,  B-,  B'^,  the  vertical  lines:  C^,  C",  the  oblique  lines, 
fissure  of  Rolando  and  fissure  of  Sylvius;  K^,  A'-,  the  course  of  the  anterior 
and  posterior  branches  of  the  middle  meningeal  artery.  Site  of  exposure  for 
ligation.  The  quadrilateral  space  A'=,  L,  M,  X.  corresponds  to  portion  of  bone 
to  be  removed  to  gain  access  to  abscess  in  the  temporo-sphenoidal  lobe. 


The  fissure  of  Eolando  may  be  mapped  out  upon  the  scalp  by 
drawing  a  line  from  a  point  Y^  inch  behind  the  mid-point  21,  upon 
the  sagittal  line,  downward  and  forward  at  an  angle  of  6Ti/o°  with 
the  sagittal  line. 

IvROXLEix's  Schema  consists  of  two  horizontal  parallel  lines, 
three  vertical  parallel  lines,  and  two  oblique  lines. 

A.     Horizontal  Lines. —  1.  The  German  base  line  passing  from 


68 


HEAD  AND  FACE. 


the  inferior  border  of  the  orbital  cavity  through  the  upper  border 
of  the  external  auditory  meatus. ' 

2.  The  superior  horizontal  line  running  parallel  with  the  base 
line  backward  from  the  upper  margin  of  the  orbital  cavity. 

B.  Vertical  Lines. — 1.  The  anterior,  erected  from  the  middle 
of  the  zygomatic  arch. 

2.  The  middle,  from  the  location  of  the  temporo-maxillary 
articulation. 


Fig.  43. — Kocher   Craniometer. 


3.  The  posterior,  erected  from  the  base  line  from  a  point  cor- 
responding to  the  posterior  border  of  the  mastoid  process. 

C.  Ollique  Lines. — 1.  The  Eolandic  line  drawn  from  the  point 
of  intersection  of  the  superior  horizontal  line,  with  the  anterior  ver- 
tical to  the  point  where  the  posterior  vertical  line  strikes  the  sagittal. 
The  lower  end  of  the  fissure  of  Eolando  corresponds  to  the  point 
where  the  Eolandic  line  crosses  the  middle  vertical  line. 

2.  The  Sylvian  line  is  a  line  that  bisects  the  angle  between  the 
Eolandic  line  and  the  superior  horizontal  line.    It  indicates  the  posi- 


CRANIOCEREBRAL   TOPOGRAPHY.  69 

tion  of  the  fissure  of  Sylvius,  wliicli  extends  upward  and  backward 
as  far  as  tlie  posterior  vertical  line. 

KocHER''s  Method. — According  to  the  plan  of  Kocher  the  ob- 
ject is  to  locate  the  sulcus  preecentralis  rather  than  the  fissure  of 
Eolando  as  the  guide  to  the  motor  area.  Fig.  43  shows  the  Kocher 
apparatus,  which  consists  of  several  flexible  metal  bands.  One,  equa- 
torial, that  passes  around  the  head  just  above  the  ears;  another, 
that  passes  from  before  backward  over  the  top  of  the  head,  from  the 


Fig.  44. — Various  Fissures,  etc.,  Indicated  by  Kochier  Craniometer.  E-N, 
equatorial  line;  L^,  linea  limitans;  M,  point  on  the  sagittal  line  midway  between 
the  glabella  and  the  external  occipital  protuberance.;  N-L,  linea  naso-lambdoid:a; 
P,  linea  prsecentralis.  Motor,  speech,  and  visual  areas  indicated  by  cross  lines, 
parallel  lines  and  dotted  area. 

glabella  to  the  external  occipital  protuberance,  the  sagittal  band, 
and  a  third,  meridional,  band  which  can  be  adjusted  to  determine 
and  indicate  various  meridional  lines  at  different  angles  with  the 
sagittal  line. 

Fig.  44  shows  the  lines  and  areas.  If  the  movable  meridional 
band  is  placed  at  a  point  upon  the  sagittal  band  midway  between 
the  glabella  and  external  occipital  protuberance,  and  its  lower  end 
then  moved  forward  so  as  to  make  an  angle  of  60°  with  the  sagittal 
line,  we  will  have  indicated  the  position  of  the  sulcus  prscentralis. 


70  HEAD  AND  FACE. 

This  line  may  be  called  the  linea  prsecentralis.  If  the  linea  prificen- 
tralis  is  divided  in  thirds  the  location  of  the  two  sulci  frontalis,  superior 
and  inferior,  will  be  indicated.  If  the  meridional  band  is  moved 
backward  so  as  to  form  an  angle  posteriorly  with  the  sagittal  line 
of  60°,  we  will  have  the  line  called  by  Koeher  the  linea  limitans. 
This  line  marks  the  boundary  between  the  gyrus  angularis  and  gyrus 
supra-marginalis  above  and  the  occipital  lobe  and  temporo-sphenoidal 
lobe  below.  The  linea  naso-lambdoidea  is  formed  by  moving  the 
meridional  band  backward  upon  the  sagittal  band  to  a  point  1  cm. 
above  the  lambdoid  suture  and  bringing  the  lower  free  end  of  the 
band  forward  to  the  glabella.  This  shows  the  line  of  the  Sylvian 
fissure,  etc. 

OPERATIONS  UPON  THE   HEAD. 

Improvement  in  operative  technique  and  better  understandmg  of 
the  functions  of  the  different  portions  of  the  brain  have  had  the  effect 


Fig.  45. — Doyen  Perforator  and  Burr.  The  opening  is  made  with  perforator 
and  enlarged  and  completed  with  the  burr.  The  burr  pushes  the  dura  mater 
before  it  without  Injurying  it. 

of  vastly  improving  the  results  obtained  from  operative  interference 
in  affections  of  the  brain,  and  give  promise  of  still  greater  advance 
in  this  branch  of  surgery.  In  deciding  to  interfere  in  lesions  of 
the  skull  and  brain,  the  surgeon  is  often  guided  by  the  presence  of 
very  evident  physical  signs,  such  as  depression  of  bone,  etc.;  at  other 
times  he  must  depend  upon  symptoms,  general  or  focal,  that  point 
to  the  presence  of  some  intracranial  lesion. 

Trephining. — By  trephining  we -mean,  in  a  general  way,  making 
an  opening  into,  or  resecting  a  portion  of,  the  skull.  This  operation 
is  done  to  relieve  compression  either  from  depressed  bone  or  from 
extravasated  blood,  and  to  treat  intracranial  conditions,  as  abscess, 
tumor,  etc. 

The  patient  is  placed  upon  the  back  with  a  thin  sandbag  under 
the  head.  The  table  upon  which  the  patient  rests  should  be  so  con- 
structed that  the  head  end  can  be  raised  or  lowered  during  the  course 


OPERATIONS  UPON  THE  HEAD. 


71 


Fig.  46. — Hudson's    Trephining    Instruments:      A,     brace    and    burr;     B,    spiral 
perforator;   C,   spiral  follower;  D  and  E,  small  and  large  enlarging  burrs. 


72  HEAD  AND  FACE. 

of  the  operation  if  the  patient  suffers  from  syncope^  profuse  venous 
hemorrhage,  etc. 

The  opening  in  the  skull  may  be  made  with  the  trephine,  remov- 
ing a  button  of  bone  sufficiently  large  to  give  ample  room,  or  else  a 
small  trephine  or  burr  like  that  of  Hudson  or  Doyen  may  be  used 
in  order  to  make  one  or  several  small  openings  in  the  skull,  which 
can  then  be  enlarged  or  connected  with  each  other  with  the  chisel  or 
with  a  biting  bone  forceps,  such  as  the  De  Vilbiss,  Dahlgren,  or  Hudson 
forceps,  or  with  the  Gigli  saw,  circular  saw,  or  rotary  drill.  These 
two  latter  instruments  are  driven  by  an  electric  motor.  Most  oper- 
ators prefer  instruments  worked  by  hand,  as  these  are  easier  to 
manage  and  safer  than  those  driven  by  electric  power.  (See  also 
page  86.) 

Trephining  for  Depressed  Fracture  oe  the  Skull. — If  a 
wound  is  already  present,  this  should  be  utilized,  and,  if  necessary, 
may  be  enlarged  in  order  to  expose  the  site  of  fracture.  If  no  wound 
is  present  and  the  incision  is  a  matter  of  choice,  a  crescentic  or 
crucial  incision  may  be  employed,  or  a  H-shaped  flap  be  reflected. 
In  marking  out  this  flap  the  base  should  be  below,  toward  the  pe- 
riphery, so  as  to  insure  good  blood-supply  to  the  flap.  The  incision 
reaches  through  the  periosteum  down  to  the  surface  of  the  bone,  and 
in  reflecting  the  flap  the  periosteum  should  be  included. 

After  the  site  of  the  fracture  has  been  exposed  and  spurting 
vessels  clamped  and  tied,  one  may  proceed  to  relieve  the  compression 
Ijy  elevating  depressed  bone,  clearing  out  blood-clot,  etc.  A  num- 
ber of  loose  pieces  of  bone,  entirely  detached  from  the  periosteum 
(pericranium  and  dura  mater),  may  be  found,  and  these  may  be 
removed  with  a  thumb  forceps.  We  may  find  other  fragments  loose, 
l3ut  still  attached,  at  least  in  part,  to  the  periosteum  or  dura  mater. 
These  may,  in  some  cases,  be  readily  elevated.  We  may  find  other 
depressed  fragments  so  firmly  impacted,  wedged,  that  they  cannot 
be  elevated,  and  in  order  to  get  at  these  fragments  it  may  be  neces- 
sary to  remove  a  portion  of  the  adjoining  margin  of  bone,  either 
with  the  trephine  or  the  chisel.  If  the  trephine  is  used  for  this  pur- 
pose the  periosteum  is  scraped  back,  laying  bare  the  surface  of  the  bone 
which  is  to  be  removed.  When  the  trephine  is  first  applied  the 
center  pin  should  be  lowered  beyond  the  level  of  the  cutting  edge 
of  the  crown  of  the  trephine  so  as  to  engage  in  the  bone  and  steady 
the  trephine  until  the  crown  has  cut  a  groove  within  which  it  may 
work  without   slipping,  when   the  pin  may  be   again  raised.     The 


OPERATIONS  UPOX  THE  HEAD. 


73 


trephine  should  be  so  placed  that  its  crown  will  partly  overlap  the 
edge  of  the  bone,  so  that  less  than  a  whole  button  will  be  removed 
from  the  margin  adjoining  the  impacted  fragment.  The  trephine 
is  worked  with  a  firm,  steady  vnist  movement,  and  the  groove  oc- 
casionally probed  to  ascertain  if  the  bone  is  cut  through  at  any  point. 
The  use  of  such  force  as  would  result  in  sudden,  abrupt  penetration 
of  the  skull  is  to  be  avoided.  The  button  may  be  loosened  by  gently 
prying  with  the  elevator.  If  the  Hudson  perforator  and  burr  are 
used  there  is  little  or  no  danger  of  injuring  the  dura  mater.    Bleeding 


Fig.  47.— Depressed  Fracture  of  the  Skull.     A  button  of  bone  removed  at  the 
edge  of  the  depressed  area. 

from  the  edge  of  the  bone  in  the  trephine  opening  ceases  after  a  few 
moments'  pressure  with  a  hot  gauze  pad. 

In  many  cases  the  liberation  of  an  impacted  fragment  is  best 
accomplished  by  using  the  chisel  to  cut  away  the  margin  of  the 
bone  that  holds  it  fast;  often,  with  a  few  strokes  of  the  mallet,  the 
fragment  is  freed  or  a  space  is  made  to  allow  the  use  of  the  elevator. 

Having  removed  all  loose  fragments  and  elevated  those  which 
are  still  attached  to  the  pericranium  and  dura  mater  and  rounded  off 
the  edges  of  any  defect  left  in  the  skull,  one  should  search  carefully 
for  any  loose  fragments  or  spiculse  which  may  be  concealed  under 
the  edge  of  the  opening  in  the  bone.  The  finger  or  probe  should 
be  used  for  this  purpose.  Small  pieces  may  be  washed  out  by  irri- 
gation with  hot  saline  solution  or  they  may  be  picked  out  with  a 


74  HEAD  AXD  FACE. 

forceps.  Careful  examination  should  be  made  as '  to  the  condition 
of  the  internal  table,  as  this  is  often  more  extensivel}'  fractured  than 
is  indicated  b}'  the  appearance  of  the  external  table.  The  internal 
table  is  at  times  extensively  fractured  and  depressed  when  the  cor- 
responding part  of  the  external  table  is  apparentl}^  uninjured.  Ex- 
travasated  clotted  blood,  between  the  dura  and  the  inner  surface 
of  the  bone,  or  beneath  the  dura,  between  it  and  the  pia-arachnoid, 
subdural  space,  should  be  removed  with  a  scoop  and  by  irrigation, 
and  any  severed  vessels  tied  with  fine  catgut.  If  the  dura  mater 
has  been  torn  the  edges  of  the  opening  may  be  brought  together  with 
fine  chromic  catgut  or  fine  silk  sutures. 

The  wound  in  the  scalp  may  be  closed  without  drainage  unless 
the  parts  have  been  exposed  to  the  chance  of  infection.  In  this  case, 
for  the  purpose  of  drainage,  a  narrow  strip  of  gauze  may  be  intro- 


Fig.  48. — Hartley  Chisel.     This  chisel  is  pointed,  V  shape  on  section,  and  is 
very  convenient  for  cutting  the  groove  in  the  bone. 

duced  through  one  corner  of  the  'wound  and  reaching  down  to  the 
dura  mater. 

Teephinixg  for  Inteaceanial  Hemorehage  (Middle  Me- 
ningeal) . — The  middle  meningeal  artery  is  the  usual  source  of  trau- 
matic intracranial  hemorrhage. 

The  middle  meningeal  is  a  vessel  of  considerable  size,  and  is 
given  off  from  the  upper  aspect  of  the  first  part  of  the  internal 
maxillary  a  short  distance  beyond  its  origin  from  the  external  carotid, 
as  it  (the  internal  maxillar}^)  lies  beneath  the  neck  of  the  condyle 
of  the  jaw,  between  it  and  the  internal  lateral  ligament.  The  middle 
meningeal  passes  directly  upward  between  the  two  roots  of  the 
auriculo-temporal  nerve,  which  surround  the  commencement  of  the 
artery,  toward  the  base  of  the  skull,  and  enters  the  skull  through 
the  foramen  spinosum.  This  part  of  the  middle  meningeal  artery 
is  concealed  beneath  the  external  pterygoid  muscle,  the  tendon  of 
which  is  attached  to  the  front  of  the  neck  of  the  condyle  of  the  Jaw. 
In  front  and  internal  to  this  part  of  the  artery  is  the  inferior  max- 
illary division  of  the  fifth  nerve  and  its  motor  root,  these  nerve 
branches  emerging  from  the  skull  through  the  foramen  ovale. 

After  entering  the  skull  the  middle  meningeal  runs  a  short 
distance  outward  in  a  groove  in  the  floor  of  the  middle  fossa  and 


OPERATIONS  UPON  THE  HE.\D. 


75 


then  divides  iuto  two  brandies.  The  anterior,  the  larger  branch, 
passes  forward  and  outward  across  the  floor  of  the  middle  fossa  of 
the  skull  and  across  the  anterior  angle  of  the  parietal  bone  just 
behind  the  outer  extremity  of  the  lesser  wing  of  the  sphenoid,  and 
may  be  exposed  as  it  ascends  upon  the  side  of  the  skull  at  a  point 
which  corresponds  to  the  intersection  of  two  lines   (Vogt),  one  ver- 


Fig.  49. — Temporary  Resection  of  the  Skull.     Holes  have  been  bored  in  the  bone 
preparatory  to  the  use  of  the  biting  bone-forceps  or  Gigli  saw. 

tical,  a  thumb's  breadth  behind  the  external  angular  process,  and, 
the  other,  horizontal,  placed  two  fingers'  breadth  above  the  zygoma. 
By  measurement  the  location  of  the  anterior  branch  of  the  middle 
meningeal  is  found  one  and  one-half  inches  behind  and  one-quarter 
inch  above  the  external  angular  process,  or  it  may  be  located  by 
finding  the  point  two  inches  above  the  middle  of  the  zygomatic  arch. 
The  posterior  branch  of  the  middle  meningeal  passes  outward  across 


76  HEAD  AND  FACE. 

the  squamous  portion  of  the  temporal  bone  and  then  ascends  up- 
ward and  backward  upon  the  inner  surface  of  the  posterior  inferior 
portion  of  the  parietal  bone  above,  and  in  front  of,  the  groove  seen 
here  for  the  lateral  sinus.  The  posterior  branch  may  be  exposed  by 
removing  a  button  of  bone  whose  center  is  one  inch  above  and  one- 
half  inch  behind  the  external  auditory  meatus.     (See  Fig.  69.) 


Fig.  50.— Temporary  Resection  of  tlie  SkuU.    The  osteo-tegumentary  flap  has 
been   reflected,    exposing   the   dura   mater. 

The  middle  meningeal  and  its  branches  ramify  in  the  dura  and 
groove  the  surface  of  the  bones  against  which  they  are  applied.  The 
anterior  branch,  as  it  approaches  the  anterior  inferior  angle  of  the 
parietal  bone,  is  lodged  in  a  deep  groove,  which  is  occasionally  con- 
verted into  a  complete  bony  canal. 

Temporary  Resection  of  the  Skull. — When  the  skull  is  intact, 
it  is  preferable,  in  order  to  gain  access  to  the  cranial  cavity,  to  do 


OPERATIONS  UPON  THE  HEAD. 


77 


a  temporary  resection  of  the  sknll  (Wagner),  turning  back  a  flap, 
whicli  consists  of  the  soft  parts,  periosteum,  and  corresponding  piece 
of  bone,  rather  than  to  remove  a  button  of  bone,  whicli  leaves  a  per- 
manent defect  in  the  skull.  This  method  of  opening  the  skull  has 
marked  a  great  advance  in  head  surgery,  in  providing  ample  room 
for  operations  upon  the  brain,  etc.  To  reach  the  middle  meningeal 
artery  or  its  divisions  this  is  a  most  satisfactory  method. 

A  horseshoe-shaped  flap  is  marked  out  in  the  temporal  region, 
with  its  arch  above  and  its  base  below  at  the  zygoma,  the  anterior 
leg  being  placed  a  good  finger's  breadth  behind  the  external  angular 
process  and  the  posterior  leg  just  in  front  of  the  tragus.  The  in- 
cision penetrates  through  the  soft  parts,   including  the   periosteum. 


Fig.  51. — Hudson-De  Vilbiss  Bone-forceps. 


down  to  the  bone.  The  flap  thus  marked  out  should  measure  in  its 
vertical  diameter  about  three  inches,  and  about  two  and  one-half 
inches  across  its  widest  part.  At  its  base  the  flap  should  be  about 
two  inches  wide.  The  temporal  artery  and  some  of  its  branches  are 
usually  divided  in  marking  out  the  flap  and  must  be  clamped  and  tied. 
Corresponding  to  the  line  of  incision  in  the  soft  parts  the  peri- 
osteum is  scraped  away  from  the  bone  for  a  distance  of  about  one- 
quarter  inch  all  around,  and  the  bone  then  cut  through.  This  can 
be  done  with  the  chisel  and  mallet  if  no  other  instruments  are  at 
hand,  although  this  method  is  rather  tedious  and  entails  considerable 
danger  of  injuring  the  dura  mater.  A  very  convenient  way  of  divid- 
ing the  bone  is  to  make  two  openings  in  the  bone,  one  in  either 
comer  of  the  upper  part  of  the  flap.  These  openings  may  be  made 
with  the  Doyen  burr  or  the  Hudson  trephine.  Working  from  either 
hole  downward  along  the  sides  of  the  flap  toward  the  base,  the  bone 
is  divided  with  biting  bone  forceps  (Dahlgren,  De  Vilbiss,  Hudson 
type).  The  bone  in  the  temporal  region  is  thin  and  is  easily  cut. 
The  bone  corresponding  to  the  upper  part  of  the  flap  may  be  divided 


78  HEAD  AXD  FACE. 

with  the  Gigli  saw.  After  the  bone  has  been  divided  all  around  the 
elevator  is  introdneed  between  the  edges  of  the  bone  and  the  seg- 
ment of  the  bone  pried  out,  breaking  it  below  through  its  base,  near 
the  zvgoma.  Additional  details  in  making  the  osteo-tegumentary 
flap  will  be  found  on  page  82. 

The  extravasated  blood  is  usually  found  between  the  dura  and 
the  bone,  so  that  as  soon  as  the  folate  of  bone  has  been  turned  back 
we  expose  the  blood,  which  is,  as  a  rule,  j^artly  clotted.  This  may 
be  cleared  out  with  a  scoop  and  irrigation  with  hot  saline,  after  which 
the  ends  of  the  divided  vessel  are  sought  and  tied.  Ordinarily  they 
may  be  seized  with  a  clamp  and  ligated  in  the  usual  manner;  there 
ma}',  however,  be  some  difficulty  in  securing  the  ends  of  the  divided 
vessel,  as  they  may  have  retracted  within  the  canal  in  the  dura  in 
which  they  are  situated  to  such  an  extent  that  they  cannot  be  readily 
seized  with  the  artery  forceps,  and  it  may  then  be  necessary  to  carry 
a  ligature  around  the  vessel  with  a  curved  needle. 

Should  the  blood  have  collected  beneath  the  dura  mater,  between 
it  and  the  pia-arachnoid  membrane,  in  the  subdural  space,  it  would 
be  necessary  to  make  an  opening  in  the  dura  in  order  to  clear  out 
the  blood.  This  condition  is  often  found  in  fractures  involving  the 
base  of  the  skull,  because  here  the  dura  is  more  intimately  adherent 
to  the  bones  and  is  therefore  more  apt  to  tear  when  this  part  of  the 
skull  is  fractured,  and  thus  the  extravasated  blood  is  permitted  to 
find  its  way  within  the  dura,  into  the  subdural  space. 

Usually  the  anterior  branch  of  the  middle  meningeal  is  the 
vessel  which  is  torn,  but  through  the  opening  made  in  the  skull  the 
posterior  branch  or  the  main  trunk  may  be  readily  reached  if  necessary. 

Having  entirely  removed  the  blood,  tied  the  ruptured  vessel,  and 
sutured  the  dura  if  it  has  been  incised  or  torn,  we  replace  the  osteo- 
tegumentary  flap  and  without  drainage  unite  the  edges  of  the  soft 
parts  all  around  with  interrupted  catgut  sutures.  At  times,  espe- 
cially in  fractures  involving  the  base,  the  oozing  continues,  and  it 
may  be  necessar\"  to  pack  loosely  with  strip  gauze  or  leave  a  strip 
of  rubber  tissue  for  drainage.  If  a  drain  is  thus  left  it  will  be 
necessary  to  leave  a  small  opening  in  the  edge  of  the  flap  for  its  exit. 

Removal  of  a  Bidton  of  Bone  with  the  Trephine. — By  removing 
a  button  of  bone  with  the  trephine  the  anterior  and  posterior  branches 
of  the  middle  meningeal  may  be  exposed  and  ligated. 

To  reach  the  anterior  branch  of  the  middle  meningeal,  an  in- 
cision, vertical,  is   made  through   the  skin,  muscle,  and  periosteum 


OPERATIONS  UPON  THE  HEAD.  79 

down  to  the  hone,  and  with  the  periosteum  elevator  the  surface  of 
the  bone,  corresponding  to  the  intersection  of  Vogt's  lines,  is  laid 
bare  (see  Fig.  69).  Instead  of  using  the  vertical  incision  this  area 
of  bone  may  be  exposed  by  turning  down  a  U-shaped  flap  with  its 
base  below  near  the  zygoma.  This  flap  includes  dl  the  tissues  of 
the  scalp  and  the  periosteum,  and  is  detached  from  the  surface  of 
the  bone  with  an  elevator. 

The  trephine  is  then  used  to  remove  a  button  of  bone,  and  thus 
the  dura  is  exposed.  If  the  opening  is  not  sufficiently  large  it  may 
be  enlarged  with  the  rongeur  bone  forceps.  After  clearing  out  the 
clot,  etc.,  the  ends  of  the  vessels  are  secured  and  the  incision  in  the 
soft  parts  closed.  This  operation  may  be  performed  more  quickly 
than  the  temporary  resection  of  the  skull,  but  it  does  not  give  as 
much  room,  and  a  further  disadvantage  is  that  it  usually  leaves  a 
permanent  defect  in  the  skull. 

To  expose  the  posterior  branch  of  the  middle  meningeal  a  but- 
ton of  bone  may  be  removed  with  its  center  one  inch  above  and 
one-half  inch  posterior  to  the  external  auditory  meatus,  as  described 
above.    This  branch  is  but  seldom  injured.     (See  Fig.  69.) 

Decompression.— The  object  of  this  operation  is  to  diminish  in- 
tracranial pressure,  which  may  have  become  greatly  increased  as. the 
result  of  the  presence  of  a  tumor  or  of  a  considerable  quantity  of 
extravasated  blood  oftentimes  in  connection  with  fracture  of  the 
base  of  the  skull.  By  the  operation  of  decompression  in  the  case 
of  tumor  we  relieve  the  symptoms  due  to  the  increased  intracranial 
pressure,  headache,  vomiting,  choked  disk — impending  blindness.  In 
fracture  of  the  base  the  pressure  caused  by  the  presence  of  the 
extravasated  blood  is  diminished  and  fatal  compression  upon  the 
vital  centers  in  the  medulla  oblongata  is  avoided.  The  operation 
must  be  done  promptly  when  indicated,  and  not  withheld  until  ir- 
reparable damage  has  been  done.  The  operation  consists  in  the  re- 
moval of  a  portion  of  the  vault  of  the  skull  and  excision  of  the 
corresponding  portion  of  the  dura.  As  a  matter  of  choice  the  opera- 
tion is  usually  done  in  the  temporal  region,  on  the  right  side  in 
right-handed  people.  The  operation  may  be  done  upon  both  sides,  if 
the  indications  warrant.  In  connection  with  fracture  of  the  base 
of  the  skull  the  operation  is  done  upon  the  injured  side.  An  osteo- 
tegumentary  flap  may  have  been  reflected  for  the  purpose  of  ex- 
ploring or  removing  a  tumor  from  the  brain  and  the  condition  found 
to  be  inoperable.     Under  these  circumstances  decompression  may  be 


80 


HEAD  AND  FACE. 


practiced  by  trimming  awa}^  the  edges  of  the  piece  of  bone  in  the 
flap  for  a  distance  of  3  cm.,  including  the  periostenm,  all  around, 
and  leaving  the  flap  of  dura  mater  unsutured  or  else  excising  it. 
The  bone-scalp  flap  is  then  replaced  and  sutured  in  position.  If 
the  decompression  is  done  for  hemorrhage  in  cases  of  fracture  of 
the  base  it  may  be  necessary  to  leave  a  drain  consisting  of  a  strip 
of  gauze  and  a  strip  of  rubber  tissue. 

Decompression  may  be  practiced  in  the  suboccipital  region  for 
subtentorial  lesions. 

DECOMPRESSioisr,  Gushing.— The  opening  is  made  in  the  bone 
in  the  temporal  region,  beneath  the  temporal  muscle.    The  temporal 


Fig.  52.— Incision   for   Temporal    Decompression. 

muscle  is  a  good  protection  against  the  bulging  and  protrusion  of 
the  brain  that  occur  often  to  a  marked  degree  after  the  operation. 
A  curved  incision  with  the  convexity  upward  is  made  upon  the 
side  of  the  head.  The  incision-  commences  behind  the  ear,  at  the 
base  of  the  mastoid  process,  and  folloAvs  the  line  of  origin  of  the 
temporal  muscle  and  terminates  anteriorly  just  above  the  anterior 
part  of  the  zygomatic  arch.  The  flap  thus  marked  out,  and  consist- 
ing of  the  skin  and  subcutaneous  tissue,  is  dissected  downward  away 
from  the  fascia  covering  the  temporal  muscle.  A  vertical  incision 
is  made  in  the  temporal  fascia  and  the  bone  then  exposed  by  penetrat- 
ing bluntly  between  the  fibers  of  the  temporal  muscle  down  to  the 
bone.  The  edges  of  the  muscle  are  retracted  with  sharp  retractors. 
The  periosteum  covering  the  bone  is  incised  and  detached  with  the 


OPERATIONS  UPON  THE  HEAD. 


81 


elevator  aild  cut  away.  An  opening  is  made  in  the  bone  which  has 
been  thus  denuded.  The  bone  is  very  thin.  The  opening  may  be 
made  with  the  Hudson  or  Doyen  burr,  etc.,  or  it  can  be  made  with 
the  chisel  and  mallet.  Through  the  small  opening  thus  made  in 
the  skull  the  bone  is  gouged  away  with  a  rongeur,  etc.,  until  an  open- 


Fig.  53.— Decompressive  Operation  in  Temporal  Region  (Cushinf/).  The 
temporal  muscle  has  been  split  and  the  fibers  drawn  apart  to  expose  the  bone. 
A  large  piece  of  bone  has  been  gouged  out  and  the  dura  cut  away. 


ing  sufficiently  large  has  been  made.  Usually  a  circular  opening  with 
a  diameter  of  6  to  8  cm.  is  made.  Care  is  exercised  not  to  injure 
the  middle  meningeal  artery  when  biting  the  bone  away  with  the 
rongeur.  This  opening  uncovers  the  temporo-sphenoidal  lobe  and 
the  lowest  part  of  the  motor  area.     Hemorrhage  from  the  bone  is 

6 


82  HEAD  AND  FACE. 

controlled  by  means  described  on  page  88.  The  dura  is  opened  by 
a  crucial  incision.  Arterial  branches  in  the  dura  are  secured  before 
incising  the  dura  by  passing  sutures  around  the  vessels  in  a  small, 
curved  needle.  Care  must  be  exercised  not  to  injure  any  of  the  ves- 
sels of  the  pia-arachnoid  when  incising  the  dura.  The  dura  is  picked 
up  with  small  tenaculum  forceps  and  nicked  with  the  knife.  Through 
the  small  opening  thus  made  the  dura  is  divided  with  small,  blunt- 
pointed  scissors.  The  dura  is  excised,  all  around,  up  to  within  a 
short  distance  of  the  edges  of  the  opening  in  the  bone.  Enough 
margin  of  the  dura  is  left  to  cover  the  edges  of  the  bone  and  protect 
the  pia-arachnoid  and  the  brain,  as  they  tend  to  protrude  through 
the  opening  in  the  skul-l  on  account  of  the  increased  intracranial 
pressure. 

The  edges  of  the  split  muscle  and  the  temporal  fascia  are  brought 
together  and  accurately  sutured  with  a  sufficient  number  of  interrupted 
chromic  catgut  sutures,  and  finally  the  skin  flap  is  sutured  all  around 
without  drainage.  If  the  operation  has  been  done  for  fracture  of 
the  base  and  the  hemorrhage  persists,  it  may  be  necessary  to  leave 
a  strip  of  gauze  and  one  or  two  strips,  of  rubber  tissue  for  drainage. 

Cerebellar  Decompresson.— The  decompression  operation  may 
be  practiced  in  a  similar  manner  in  the  region  of  the  cerebellum, 
by  removing  a  part  of  the  bony  wall  in  the  occipital  region  in  order 
to  relieve  pressure  in  this  part  of  the  skull.  The  skin  incision  and 
the  several  steps  of  the  operation  are  similar  to  those  described  for 
gaining  access  to  the  cerebellum  for  the  purpose  of  excising  tumors, 
etc.,  in  this  part  of  the  brain.  (See  page  93.)  An  opening  may 
have  been  made  in  the  skull  for  the  purpose  of  removing  a  tumor, 
etc.,  and  the  condition  found  to  be  inoperable.  Under  these  circum- 
stances decompression  may  then  be  practiced  as  a  palliative  measure. 

The  bone  is  extensively  removed  from  mastoid  to  mastoid,  and 
from  the  external  occipital  crest  to  the  margin  of  the  foramen  mag- 
num, including  the  posterior  half  of  the  margin  of  the  foramen 
magnum  itself.  The  flap  of  dura  mater  is  excised  and  the  flap  of 
scalp  sutured  back  in  place  without  drainage.     (See  Fig.  61.) 

Craniotomy,  Osteo-te^mentary  Flap  Method. — To  expose  dif- 
ferent parts  of  the  brain  for  the  purpose  of  removing  tumors,  etc. 
The  location  of  the  flap  will  vary  according  to  the  position  of  the 
lesion. 

A  great  advance  in  the  surgery  of  the  brain  has  been  made  pos- 
sible by  the  introduction  of  the  osteo-tegumentary  flap  method   of 


OPERATIONS  UPON  THE  HEAD. 


83 


opening  the  skull  and  by  the  better  understanding  of  methods   of 
localizing   processes   affecting   particular   areas   of   the   brain. 

Operations  involving  incision  of  the  brain  or  much  handling  or 
manipulation  of  the  brain  may  be  done  in  two  acts  separated  by  an 
interval  varying  from  several  days  to  several  weeks.  The  first  act 
consists  in  making  the  opening  in  the  skull  and  incising  the  dura 
mater.  If  the  loss  of  blood  has  been  very  great  it  may  be  wise  to 
discontinue  the  operation  after  the  osteo-tegumentary  flap  has  been 
turned  down  and  before  opening  the  dura.     The  second  act  consists 


Fig.  54. — Location    of   Various    Skull    Flaps    (Mills).     To    gain    access   to    certain 
definite  parts  of  the  brain. 

in  incising  the  brain  for  the  removal  of  tumor;  for  cyst,  abscess, 
epilej)sy,  etc.,  or  in  retracting  or  lifting  the  brain  away  from  its 
bed  to  gain  access  to  tumors,  etc.,  lying  deep  in  the  skull,  underneath 
the  lobes  of  the  brain,  and  extirpation  of  the  same;  excision  of  the 
Gasserian  ganglion,  etc. 

The  decision  to  complete  the  operation  in  one  seance  will  depend 
upon  the  patient's  condition  after  completion  of  the  first  act, — after 
the  dura  has  been  opened, — as  indicated  by  the  blood-pressure,  amount 
of  blood  lost  during  the  first  part  of  the  operation,  shock,  etc.  Oper- 
ators of  large  experience  strongly  advocate  the  plan  of  postponing 
the  second  act  if  any  doubt  exists  at  all  as  to  the  patient's  ability 
to  withstand  the  shock  of  the  entire  operation.     AVhere  the  opera- 


84  HEAD  AND  FACE. 

tion  is  done  in  two  separate  acts  the  second  may  be  postponed  for 
a  period  of  several  days  or  several  weeks,  until  the  patient  has  fully 
recovered  from  the  effect  of  the  first  operation.  If  it  is  decided  to 
postpone  the  second  act  the  opening  in  the  dura  is  sutured  and  the 
osteo-tegumentary  flap  replaced  and  sutured  accurately.  After  the 
lapse  of  several  days  or  weeks  the  flap  may  again  be  readily  turned 
down.  The  bone  segment  will  be  found  to  be  still  loose,  so  that  this 
flrst  step  of  the  operation  can  be  accomplished  without  shock  and 
without  loss  of  blood. 

The  patient  lies  upon  a  table,  the  upper  part  of  which  may  be 
readily  raised  or  lowered  as  may  be  necessary  during  the  course  of 
the  operation;  the  head  upon  the  side,  resting  upon  a  flat  sandbag. 
It  is  usually  convenient  to  have  the  upper  part  of  the  table  elevated 
so  that  the  patient  is  in  a  semi-reclining  position.  The  patient  must 
be  kept  warm  during  the  operation.  The  best  ansesthetic  is  prob- 
ably ether  given  by  an  experienced  ansesthetist,  and  preceded  by  the 
administration  of  morphin  hj^podermically.  If  the  operation  is  done 
in  two  seances  the  second  may  often  be  accomplished  with  very  light 
ether  anaesthesia  or  under  local  cocain  anaesthesia. 

The  entire  head  is  shaved  the  day  before  operation,  and  the 
principal  landmarks,  the  Rolandic  and  Sylvian  fissures,  etc.,  marked 
upon  the  scalp  with  some  indellible  material — a  solution  of  nitrate 
of  silver,  thirty  grains  to  the  ounce.  This  is  brushed  over  with  a 
solution  of  pyrogallic  acid,  five  grains  to  the  ounce.  The  markings 
are  thus  fixed  and  will  not  be  erased  when  the  scalp  is  washed.  The 
location  of  the  osteo-tegumentary  flap  will  vary  according  to  the  posi- 
tion of  the  lesion,  in  the  frontal,  parietal,  occipital  lobes,  etc. 

In  the  Parietal  Eegion  to  Expose  the  Motor  Area,  etc. — 
A  horseshoe-shaped  flap  with  the  base  below,  or  the  flap  may  be  rect- 
angular in  shape,  is  marked  out  in  the  parietal  region.  The  incision 
penetrates  through  all  of  the  soft  parts,  including  the  periosteum, 
down  to  the  bone. 

As  a  rule  the  flajD  will  measure  about  3  inches  in  its  long  (ver- 
tical) diameter,  214  to  3  inches  across  its  widest  part,  and  2  to  3% 
at  its  base.  Bleeding  points  are  secured  with  strong,  narrow-nosed 
hemostats.  At  times  the  hemorrhage  from  the  soft  parts  is  very 
profuse,  especially  in  the  presence  of  the  increased  intracranial  pres- 
sure that  accompanies  tumor,  large  blood  and  pus  collections  within 
the  skull,  and  means  must  be  taken  to  prevent  excessive  loss  of  blood. 
According  to  the  plan  of  Gushing,  this  is  accomplished  by  encircling 


OPERATIONS  UPON  THE  HEAD. 


85 


the  head,  just  above  the  ears,  with  a  strong  elastic  constricting  band, 
which  is  prevented  from  slipping  down  over  the  face  by  a  strip  of 
tape  which  occupies  the  middle  (sagittal)  line  and  secures  the  con- 
stricting band  in  front  and  behind.  This  arrangement  may  be  adapted 
to  the  size  of  the  patient's  head  before  operation,  and  is  then  sterilized 
and  ready  for  use.  It  is  applied  over  a  sheet  of  gauze  which  covers 
the  patient's  head.  The  sheet  of  gauze  may  be  cut  into  four  quarters 
by  a  crucial  cut,  and  the  four  ends  of  the  gauze  turned  down  over 
the  patient's  ears,  face,  etc. 


Fig.  55. — Kredel's  Blocks  in  Position.     Above  a  single  block  and  a  cross-section 

of  the  same. 


The  method  of  Heidenhain  for  controlling  hemorrhage  consists 
in  applying  a  line  of  suture  with  a  heavy  silk  thread — back-stitch 
fashion — ^beyond  and  all  around  the  line  of  the  proposed  incision  in 
the  scalp.  This  suture  is  introduced  with  a  heavy,  curved  needle, 
and  each  stitch  penetrates  the  entire  thickness  of  the  scalp  down  to 
the  bone,  taking  a  good,  secure  bite.  Kredel's  metal  blocks  may  be 
used.  These  are  grooved  and  notched  at  the  extremities  and  are 
applied  all  around,  beyond  the  line  of  the  proposed  flap.  Long 
stitches  of  heavy  silk  are  carried  under  the  scalp  so  as  to  secure  its 
entire  thickness,  and  these  are  tied  over  the  blocks.  The  sutures 
are  prevented  from  slipping  by  the  grooves  and  notches  in  the  blocks. 
Hemorrhage  from  the  edges  of  the  flap  itself  is  controlled  by  hemostats 


86 


HEAD  AND  FACE. 


and  ligatures.  Corresponding  to  the  edges  of  the  flap,  the  periosteum 
is  scraped  away  from  the  bone  for  a  distance  of  about  14  inch  all 
around  in  order  to  make  way  for  the  trephine,  saw,  etc.,  in  dividing 
the  bone. 

Different   operators   employ   different   methods   for  making  the 
cut  in  the  bone.    The  most  convenient  plan  is  to  make  two  openings 


Fig.  56.— Formation  of  the  Osteo-tegumentary  Flap   (Marion). 


in  the  bone  corresponding  to  either  end  of  the  upper  part  of  the 
incision.  These  openings  may  be  made  with  the  Doyen  or  the  Hudson 
perforators  and  burr.  With  these  instruments  the  danger  of  abruptly 
penetrating  and  injuring  the  dura  and  underlying  structures  is  elimi- 
nated. The  Doyen  burr  is  smooth,  non-cutting  on  its  under  side, 
and  will  push  the  dura  away  without  injuring  it,  and  the  Hudson 
instrument  stops  working  automatically  just  as  soon  as  the  bone 
has  been  penetrated.  Working  from  either  hole  downward  along  the 
sides  of  the  flap  toward  the  base,  the  bone  is  divided  with  a  biting  bone 
forceps  of  the  Dahlgren,  De  Yilbiss,  Hudson  type.     The  bone  cor- 


OPERATIONS  UPON  THE  HEAD.  87 

responding  to  the  upper  part  of  the  flap  may  also  be  cut  with  the 
bone  forceps,  but  it  is  better  to  do  this  with  the  Gigli  saw.  The 
Gigli  saw  is  passed  through  from  one  hole  to  the  other  and  the  bone 
between  the  two  holes  sawn  through.  The  section  through  the  bone 
at  this  part  should  be  made  upon  an  oblique  plane  so  that,  when 
the  flap  is  replaced,  the  segment  of  bone  will  present  a  beveled  edge 
to  rest  upon  the  corresponding  broad,  beveled  edge  of  bone,  and  thus 
prevent  it  from  being  pressed  inward  upon  the  dura  or  brain.  Before 
using  the  bone  forceps  and  before  passing  the  Gigli  saw  the  dura 
must  be  separated  from  the  under  surface  of  the  bone.     This  is  ac- 


Fig.  57. — Formation  of  the  Osteo-tegumentary  Flap   (Uarion).     Passing  the  Gigli 
saw  from  hole  to  hole. 

complished  by  introducing  the  separator  through  one  of  the  trephine 
openings  and  working  it  cautiously  between  the  dura  and  bone  as 
far  as  the  next  ojDening  or  in  the  direction  that  is  to  be  cut  with 
tbe  forceps.  The  gTooved  separator  of  Marion,  which  is  elastic  and 
bendable,  so  that  its  extremity  can  be  bent  to  suit  the  immediate 
necessities  of  the  case,  is  a  very  satisfactory  instrument  for  the  pur- 
pose. If  the  Gigli  saw  is  used  it  is  carried  through  from  hole  to 
hole  upon  the  grooved  separator,  or  it  may  be  drawn  through  if  neces- 
sary with  a  silk  thread  in  the  eye  of  the  separator.  The  separator 
is  left  in  situ  while  the  bone  is  being  sawn  through  with  the  Gigli 
saw,  in  order  to  protect  the  dura,  etc.,  from  injury.  Several  openings 
— four  or  five — may  be  made  in  the  bone  with  the  trephine,  one 
at  each  end  of  the  base  of  the  flap  (each  lower  corner),  one  at  each 


88  HEAD  AND  FACE. 

upper  corner^  and  one  between  these  two  latter,  and  the  bone  between 
the  openings  cut  through  from  hole  to  hole  with  the  Gigli  saw.  The 
opening  in  the  skull  should  not  reach  to  within  %  to  1  inch  of  the 
sagittal  line,  on  account  of  the  danger  of  injuring  the  parasinoidal 
lacunse.  After  the  bone  has  been  divided  all  around,  the  elevator 
is  introduced  between  the  edges  of  the  bone  in  the  upper  part  of 
the  flap  and  the  piece  of  bone  pried  out,  breaking  it  below,  through 
its  base.  The  fracture  through  the  base  may  be  facilitated  by  one 
or  two  blows  with  the  chisel  and  mallet.  A  guarded  chisel  is  used 
for  this  purpose,  similar  to  the  Doyen  (Fig.  60).  During  the  course 
of  this  part  of  the  operation  care  must  be  taken  not  to  detach  the 
soft  parts  from  the  segment  of  bone  in  the  flap.  The  flap,  which 
thus  consists  of  all  the  soft  parts  with  the  corresponding  segment 
of  bone  attached,  is  turned  down  over  the  zygoma,  leaving  a  con- 
siderable opening  in  the  skull  through  which  the  dura  mater  and  the 


Fig.  58. — Marion  Separator  and  Conductor. 


branches  of  the  middle  meningeal  arterj^,  which  ramify  in  it,  are 
exposed. 

If  the  opening  in  the  skull  is  not  sufficiently  large,  it  may  be 
further  enlarged  by  cutting  away  its  margins  with  the  bone  forceps. 

There  may  be  considerable  hemorrhage  from  the  edges  of  the 
bone.  This  is  usually  readily  controlled  by  packing  temporarily  with 
gauze.  If  it  persists  and  is  coming  from  one  or  several  larger  open- 
ings in  the  bone,  it  may  be  controlled  by  crushing  the  bone  with  a 
blow  of  the  blunt-end  chisel  or  with  Krause's  hooks,  ivory  pegs,  or 
with  Horsley's  wax — a,  putty-like  mass  made  up  of  vaselin  and  par- 
affin, each  50  parts,  and  carbolic  acid  5  parts.  It  may  be  necessary 
to  interrupt  the  operation  before  opening  the  dura  if  the  hemorrhage 
has  been  very  severe. 

After  the  osteo-tegumentary  flap  has  been  reflected  the  dura  is 
incised.  The  dura  is  incised,  flap-fashion,  usually  with  the  base  of 
the  flap  below.  It  should  not  be  divided  too  close  to  the  edges  of  the 
opening  in  the  bone  in  order  that  there  may  be  ample  margin  left  for 
suturing.  If  the  upper  part  of  the  opening  in  the  skull  is  quite  close 
to  the  middle  (sagittal)  line  it  will  be  advisable  to  incise  the  dura 


OPERATIONS  UPON  THE  HEAD. 


89 


aroniid  the  lower  part  of  its  circumference  in  such  a  way  that  the 
base  of  the  dura  flap  is  above,  in  order  to  avoid  injuring  the  parasi- 
noidal lacunar  which  often  spread  out  over  the  hemispheres  for  some 
distance — %  to  1  inch — away  from  the  middle  line.  Care  must  be 
exercised  in  incising  the  dura  not  to  injure  the  pia-arachnoid.  A 
hemorrhage  may  result,  small  in  itself,  but  very  annoying  in  that 
it  spreads  in  the  subarachnoid  space  and  may  obscure  the  fissures 
and  convolutions.  The  dura  is  picked  up  with  a  fine  tenaculum, 
nicked  with  the  knife,  and  then  carefully  incised  with  the  blunt- 


Fig.  59. — Formation    of    the    Osteo-tegumentary    Flap    (Marion). 
hole  to  hole  with  the  Gigli  saw. 


Cutting    from 


pointed  scissors.  This  may  be  rather  difficult  on  account  of  the  very 
marked  degree  of  bulging  and  tension  of  the  dura.  If  the  opening 
in  the  skull  is  found  to  be  not  large  enough,  more  room  may  be  ob- 
tained by  gouging  away  the  edges  of  the  bone  or  by  reflecting  an 
additional  osteo-tegumentary  flap  from  either  one  side  or  the  other. 
In  gnawing  aM^ay  the  upper  edge  of  the  opening  in  the  bone  great 
care  must  be  taken  to  carefully  detach  the  dura  (including  the 
parasinoidal  lacunte,  longitudinal  sinus,  etc.)  before  applying  the 
forceps  to  the  bone.  If  necessary  to  enlarge  the  opening  in  the  dura 
incisions  may  be  made  in  the  corners  of  the  dura  radiating  from  its 
cut  edges  toward  the  edges  of  the  bone.  A  tumor  may  be  found 
growing  from  the  dura  against  the  surface  of  the  brain  or  the  dura 


90 


HEAD  AND  FACE. 


ma)''  be  adherent  to  the  pia-arachnoicl  or  involved  in  a  new  growth 
in  the  brain.  Under  these  circumstances  the  dura  must  be  carefully 
separated  and  excised  if  necessary.  Occasionally  the  brain  bulges  de- 
cidedly just  as  soon  as  the  opening  is  made  in  the  dura  on  account 
of  the  greatly  increased  intracranial  pressure,  and  this  bulging  may 
become  very  much  increased  during  the  course  of  the  operation 
through  the  oedema  and  swelling  of  the  arachnoid,  which  may  result 
from  exposure,  handling,  etc.  It  may  be  necessary  to  puncture  and 
express  the  fluid  or  to  resort  to  lumbar  puncture,  etc.  The  examina- 
tion with  the  object  of  determining  whether  to  continue  with  the 
second  act  of  the  operation  or  to  postpone  this  part  of  the  operation 
should  therefore  be  made  as  quickly  and  with  as  little  handling  as 
possible.  There  may  be  difficulty  in  returning  the  brain  mass  and 
replacing  the  flap  if  the  oedema  becomes  very  marked. 


Fig.  60. — Doyen   Guarded  Chisel. 


After  the  surface  of  the  brain,  covered  by  its  pia-arachnoid,  has 
been  exposed,  and  if  we  decide  to  continue  with  the  operation,  we 
are  ready  for  the  next  step.  A  tumor,  angioma,  cyst,  abscess,  may 
present  itself  and  be  removed  or  incised  and  drained.  There  may 
be  no  positive  evidence  presented  of  a  tumor,  cyst,  etc.,  upon  ex- 
posing the  brain.  The  color,  consistence,  lack  of  pulsation,  bulging, 
etc.,  may  be  of  assistance  in  this  case,  or  it  may  be  necessary  to 
search  for  evidence  of  disease  by  puncture,  aspiration.  A  large-bore 
needle  (2  mm.  diameter)  and  a  syringe  of  capacity  of  2  to  3  c.c.  are 
used  for  this  purpose.  Cystic,  bloody,  or  purulent  fluid  may  be  with- 
drawn, or  a  cylinder  of  brain  or  tumor  tissue  may  be  withdrawn  for 
immediate  examination.  Tumor  may  be  encapsulated  and  may  thus 
be  readily  enucleated  with  the  finger  or  blunt  dissector.  Cysts, 
alDscesses,  may  be  incised,  emptied,  the  wall  dissected  out,  and  the 
cavity  packed.  This  must  all  be  done  in  the  gentlest  manner  pos- 
sible. If  necessary  to  incise  the  cortex,  the  incision  should  be  con- 
fined to  the  summit  of  a  convolution,  and  should  not  cross  a  sulcus. 
Before  making  the  incision  the  blood-vessels  of  the  pia-arachnoid 
corresponding  to  the  proposed  line  of  incision  must  be  tied  double 
with  very  fine  silk,  which  is  passed  around  them   in  a  fine,  curved 


OPERATIONS  UPON  THE  HEAD.  91 

needle.  It  is  practically  impossible  to  define  the  limits  of  diffuse 
tumors,  and  it  is  very  questionable  whether  the  effort  should  be  made 
to  remove  them.  The  walls  of  the  cavity  which  is  left  after  enuclea- 
tion of  a  tumor,  evacuation  of  a  cyst,  etc.,  usually  collapse,  and  thus 
the  cavity  is  obliterated  to  a  considerable  extent.  Hemorrhage  from 
the  cavity  is  controlled  by  packing  it  temporarily  with  strip  gauze. 
After  a  few  minutes  the  hemorrhage  usually  ceases.  If  the  cavity 
is  small,  clean,  and  there  is  no  hemorrhage,  the  opening  in  the  skull 
may  be  closed  without  drainage.  If  the  cavity  is  large,  or  if  oozing 
continues,  it  will  be  necessary  to  leave  the  packing  in  place  for  forty- 
eight  hours.     Abscess  and  cyst  cavities  must  be  packed  and  drained. 

For  Epilepsy. — After  the  dura  has  been  opened  it  will  be  neces- 
sary to  accurately  locate  the  area  which  is  to  be  excised.  This  is 
done  by  faradization.  A  long,  sterilizable,  glass,  unipolar  electrode 
30  cm.  long,  provided  with  a  fine  platinum-wire  core,  twisted  into  a 
spiral  at  the  end,  is  used.  The  other  pole  is  applied  to  the  trunk 
or  to  one  of  the  extremities,  preferably  upon  the  homo-lateral  side. 
The  current  should  not  be  strong — just  strong  enough  to  give  ap- 
preciable burning,  sour  taste  when  applied  to  the  tip  of  the  tongue 
or  to  cause  contraction  of  some  exposed  muscle-fiber;  some  of  the 
temporal  fibers  in  the  flap  may  be  available  for  this  purpose.  If  the 
pia-arachnoid  contains  too  much  cerebro-spinal  fluid  it  may  be  neces- 
sary to  prick  the  pia  where  it  bridges  over  a  sulcus  and  allow  some 
of  the  fluid  to  escape.  The  patient  should  not  be  too  deeply  anass- 
thetized.  The  portion  of  the  cortex  which  is  to  be  excised  is  thus 
marked  out.  All  the  blood-vessels  leading  to  the  area  which  is 
to  be  excised  are  tied  double  with  fine  silk  ligatures  carried  around 
them  in  a  fine  curved  needle  and  the  area  of  the  cortex  then  excised, 
cutting  well  into  the  white  substance. 

Closure  of  the  Wound. — If  no  drainage  is  necessary  the  wound 
is  closed  by  suturing  the  dura  all  around  with  very  fine  chromic  cat- 
gut or  fine  silk.  The  flap  is  replaced  and  the  edges  of  the  skin  are 
sewn  together  very  accurately  with  interrupted  silk  sutures.  These 
sutures  take  as  deep  a  bite  as  possible  in  the  edges  of  the  flap,  are 
placed  close  together  and  drawn  tight  to  control  any  tendency  to 
hemorrhage  from  the  scalp.  If  it  is  desired  to  drain,  an  opening 
is  left  in  the  lower  posterior  corner  of  the  dura  and  a  piece  of  bone 
bitten  out  to  correspond.  Occasionally  the  bulging  is  so  great  that 
it  is  impossible  to  suture  the  dura  or  to  replace  the  flap.  Under  these 
circumstances  it  may  be  necessary  to  leave  the  wound  open.     The 


92  HEAD  AND  FACE. 

swelling  and  bulging  will  often  subside  in  a  few  days  so  as  to  permit 
replacement  of  the  flap. 

To  Expose  the  Cerebellum  and  Other  Parts  Contained  in 
THE  Posterior  Fossa  (Cushing). — The  patient  lies  npon  the  table, 
face  downward,  with  the  head  projecting  over  the  end  of  the  table 
and  supported  npon  an  extension  with  a  rest  adapted  to  receive  the 
head.  The  shoulders  are  raised  from  the  surface  of 'the  table  upon 
sandbags  in  order  to  permit  free,  respiratory  movement  of  the  chest. 
The  operation  may  also  be  done  with  the  patient  in  the  semiprone 
position,  with  the  shoulder  raised  upon  a  sandbag  to  permit  of 
freedom  of  respiration. 

The  cross-bow  incision  is  made.  The  upper  part  of  the  incision 
is  curved,  passing  across  the  back  of  the  head  from  the  base  of  one 
mastoid  process  to  the  base  of  the  other,  above  and  parallel  with 
the  superior  curved  line  of  the  occipital  bone.  Another  incision  is 
made  in  the  middle  line,  which  reaches  from  the  upper  incision 
downward  as  far  as  the  spine  of  the  second  or  third  cervical  vertebra. 
The  flaps,  which  consist  of  all  the  soft  parts  and  including  the  peri- 
osteum, are  detached  from  the  bone,  which  is  thus  denuded  as  far  as 
the  foramen  magnum.  In  detaching  and  cutting  the  muscular  at- 
tachment (of  the  trapezius)  to  the  superior  curved  line  of  the  occipital 
bone,  care  is  taken  not  to  divide  it  too  close  to  the  bone  so  that  a 
sufficient  margin  may  be  left  for  suturing  in  closing. 

The  bone  on  both,  sides  of  the  middle  line  is  perforated  with  the 
trephine  and  the  bone  then  gouged  away,  upward  as  far  as  the  lateral 
sinus  so  that  the  course  of  the  sinus  is  exposed,  inward  across  the 
middle  line,  but  leaving  intact  the  portion  of  bone  over  the  torcular, 
and  finally  downward  as  far  as  and  including  the  posterior  half  of 
the  margin  of  the  foramen  magnum.  The  posterior  arch  of  the  atlas 
is  thus  exposed  in  the  wound.  The  dura  is  incised  all  the  way  across 
and  turned  down  flap^fashion.  It  will  be  necessary,  before  carrjdng 
the  incision  across  the  middle  line,  to  ligate  the  occipital  sinus.  This 
is  done  by  incising  the  dura  on  each  side  of  the  middle  line  and 
carrying  a  ligature,  double,  around  the  sinus  in  a  curved  carrier. 
The  ligature  passes  around  the  entire  width  of  the  falx  cerebelli 
(which  is  easily  done,  as  the  falx  is  quite  narrow) .  The  ligature 
is  divided  and  tied  double,  one  above  and  the  other  below,  and  the 
sinus  and  falx  cerebelli  cut  between  the  two  ligatures  and  the  dura 
flap  turned  down.  Both  cerebellar  hemispheres  are  thus  freely  ex- 
posed. 


OPERATIONS  UPON  THE  HEAD. 


93 


Fig.  61. — Exposure    of    Cerebellum, 
sinus  ligated  and 


Bone    has   been    cut    away, 
flap  of  dura  turned  down. 


The    occipital 


94 


HEAD  AND  FACE. 


The  second  act  of  the  operation  is  proceeded  with  or  postponed 
for  a  later  da}^,  according  to  the  condition  of  the  patient,  as  indicated 
h}^  blood-pressure,  amount  of  blood  lost,  shock,  etc.  If  the  operation 
is  to  be  done  in  two  separate  stages  the  flap  of  dura  is  sutured  and 
the  muscle-skin  flap  is  replaced  and  accurately  sutured,  and  the  pa- 
tient allowed  to  recover  fully — several  days  to  several  weeks  are 
allowed  to  elapse— before  proceeding  with  the  second  step.  Decom- 
pression may  be  done  here  if  an  inoperable  condition  is  found,  by 
resecting  the  flap  of  dura. 


Fig.  62.— CusMng   Cross-bow   Incision. 


Exposure  of  One  Half  of  the  Cerebellum  (Krause). — The 
osteo-tegumentary  flap,  method  may  be  used  to  expose  one  half  of  the 
cerebellum.  It  has  no  advantages  and  gives  less  satisfactory  access 
to  the  posterior  fossa  than  where  the  bone  is  sacrificed.  This  method 
may  be  employed,  however,  where  a  definitely  localized  and  easily 
accessible   tumor   has  been   diagnosticated. 

A  quadrangular  flap  is  marked  out,  the  upjoer  border  of  which 
corresponds  to  a  line  that  passes  transversely  outward  across  the  back 
of  the  head  from  a  point  one-half  inch  above  and  to  the  other  side 
of  the  external  occipital  protuberance  to  the  base  of  the  mastoid 
process.  From  either  end  of  this  transverse  incision,  two  other  in- 
cisions, one  on  each  side,  are  carried  straight  downward,  the  outer 
one  corresponding  to  the  posterior  border  of  the  mastoid  process. 


OPERATIONS  UPON  THE  HEAD. 


95 


Fig.  63. — Exposure  of  One-half  of  the  Cerebellum.  Osteo-plastic  Flap 
(Kransc).  Ligature  of  occipital  sinus  preparatory  to  turning  down  a  flap  of 
dura. 


96  HEAD  AND  FACE. 

the  inner  one  running  parallel  with  and  just  a  little  to  the  other  side 
of  the  external  occipital  crest.  Two  trephine  openings  are  made,  one 
in  either  upper  corner.  These  expose  the  lateral  sinus  or  the  dura 
mater  just  above  the  course  of  the  sinus.  The  dura  is  carefully  sep- 
arated and  the  bone  cut  with  the  biting  forceps  from  hole  to  hole, 
and  then  downward  along  either  lateral  incision.  The  bone  is  broken 
along  the  lower  border  of  the  flap  and  the  flap  turned  down.  The 
edges  of  the  opening  in  the  bone  should  be  gouged  away  so  as  to  ex- 
pose the  position  of  the  lateral,  sigmoid,  and  occipital  sinuses.  The 
dura  is  incised,  not  too  close  to  the  margin  of-  the  opening  in  the 
bone,  and  reflected  downward,  flap-fashion. 

To  obtain  still  more  room  in  the  suboccipital  region  a  much 
larger  flap,  reaching  well  into  the  other  half  of  the  occipital  bone, 
may  be  reflected  and  the  division  of  the  bone  carried  as  far  down- 
ward and  forward  into  the  floor  of  the  posterior  fossa  as  possible. 
When  this  flap  is  turned  down  it  will  be  seen  that  the  segment  of  bone 
includes  the  posterior  margin  of  the  foramen  magnum.  It  may 
be  necessary  to  ligate  and  divide  the  occipital  sinus  and  falx  cer- 
ebelli.  For  this  purpose  an  incision  is  made  in  the  dura  upon  either 
side  of  the  middle  line  (falx  cerebelli)  and  the  ligature,  double,  carried 
around  the  falx  cerebelli  and  occipital  sinus  with  a  full-curved  car- 
rier. The  ligature  is  cut  and  tied  above  and  below  and  the  sinus 
and  falx  cerebelli  divided  between  the  ligatures.  The  upper  of  the 
two  ligatures  must  not  be  too  close  to  the  confluence  of  the  lateral 
and  longitudinal  sinuses — at  least  1  cm.  away.  The  ligatures  surround 
the  entire  width  of  the  falx  cerebelli,  which  is  quite  narrow  and  per- 
mits easy  passage  of  the  carrier. 

EoR  Abscess  of  the  Biiain. — ^Abscess  may  occur  in  any  part 
of  the  brain  as  a  result  of  direct  infection  from  without,  complicat- 
ing penetrating  wounds  of  the  skull,  and  compound  fractures.  Abscess 
of  the  brain  may  occur  in  head  injuries  without  local  wound,  the 
infectious  elements  gaining  access  to  the  damaged  parts  through  the 
blood-stream.  Abscesses  of  the  brain  may  be  metastatic,  secondary 
to  general  pygemic  conditions— abscess  of  the  lung,  liver,  osteo- 
myelitis, etc.  Most  commonly  abscess  of  the  brain  results  from  ex- 
tension of  a  septic  process  from  the  nasal  cavity  and  the  air  sinuses 
adjacent  to  it  or  from  the  middle  ear  and  mastoid  antrum.  The  in- 
flammatory process  extends  through  the  thin,  bony  partitions,  which 
separate  these  spaces  from  the  cranial  cavity,  or  septic  material  may 
be  carried  by  means  of  the  blood-current,  infected,  thrombosed,  emis- 


OPERATIONS  UPON  THE  HEAD.  97 

sary  veins,  etc.  These  abscesses  have  a  characteristic  predilection  for 
certain  definite  parts  of  the  brain.  Those  secondary  to  suppuration 
in  the  frontal,  sphenoidal  sinuses  are  found  in  the  frontal  lobe ;  those 
secondary  to  inflammatory  processes  in  the  middle  ear  and  mastoid 
antrum  in  the  temporo-sphenoidal  lobe.  Abscesses  located  in  the 
cerebellum  are  secondary  to  inflammation  in  the  mastoid  antrum  and 
cells  and  to  thrombosis  of  the  sigmoid  sinus. 

Abscesses  due  to  direct  infection  from  without,  complicating  a 
penetrating  wound  or  compound  fracture,  necrosis  and  suppuration 
of  the  bones  of  the  skull,  are  treated  by  enlarging  the  original  wound, 
freely  opening  the  skull  by  gouging  away  the  bone,  and  very  freely 
incising  and  packing  the  abscess  cavity.  It  is  not  advisable  to  ir- 
rigate the  abscess  cavity,  nor  should  its  wall  be  curetted  except  in 
the  case  of  chronic  (tubercular)  abscess,  with  a  distinct,  well-marked 
abscess  wall— pyogenic  membrane. 

The  pia-arachnoid  will  usually  be  found  adherent  to  the  dura, 
and  the  abscess  may  be  opened  without  danger  of  the  escaping  pus 
entering  the  subdural  space  and  being  distributed  over  the  adjacent 
parts  of  the  brain  surface.  If  the  subdural  space  has  not  already 
been  closed  off  by  adhesion  between  the  dura  and  pia-arachnoid, 
strip  gauze  should  be  packed  into  the  space  before  opening  the  abscess. 

Plan  of  operation  upon  abscesses  secondary  to  infectious  processes 
in  the  paranasal  sinuses,  frontal,  sphenoidal,  etc.,  or  in  the  middle 
ear,  mastoid  antrum,  etc.,  is  discussed  in  connection  with  the  opera- 
tions upon  these  several  parts.  It  might  be  well  to  mention  here, 
however,  that  the  cardinal  ru^e  is  to  first  freely  and  thoroughly  lay 
open  and  explore  the  cavity  which  is  the  seat  of  the  primary  infec- 
tion, find  the  path  of  infection  if  possible,  and  evacuate  and  drain  the 
brain  abscess  through  the  incision  and  wound  thus  made;  or  else, 
after  laying  open,  exploring,  and  packing  the  cavity  which  is  the 
original  focus  of  infection,  approach  and  evacuate  the  abscess  in  the 
brain  through  a  more  convenient  route — through  an  independent 
opening  in  the  side  of  the  skull,  etc. 

Puncture  of  the  Brain  and  Ventricles  for  Diagnostic 
Purposes. — A  small  incision  is  made  in  the  scalp  under  cocain  or 
ethyl  chlorid  anaesthesia.  The  opening  is  made  in  the  skull  with  a 
drill  driven  by  a  motor,  the  drill  held  lightly  and  steadily  against 
the  skull.  At  the  moment  the  skull  is  penetrated  the  fact  is  readily 
appreciated  by  the  operator.  There  is  but  little  danger  of  going 
through  the  dura  abruptly  with  the   drill,  but   even  if  this  occurs 


98  HEAD  AND  FACE. 

no  damage  will  be  done.  A  very  small  burr — 2  mm.  in  diameter — 
is  used.  The  aspirating  needle  is  introdnced  through  the  hole  in 
the  skull  and  then  pushed  through  the  dura  into  the  brain.  A  needle 
7  cm.  in  length  with  a  calibre  1  mm.  in  diameter,  and  provided  with 
a  steel  mandrin,  is  used.  The  needle  is  graduated  in  cm.  in  order 
to  determine  the  depth  of  fluids  and  tissues  withdrawn.  The  needle 
is  introduced  to  various  depths,  the  mandrin  withdrawn,  and  the 
syringe  applied.  The  needle  is  then  slowly  withdrawn,  making  suc- 
tion with  the  syringe  at  the  same  time.  Fluid  or  pus  or  a  cylinder 
of  brain  or  tumor  tissue  may  thus  be  withdrawn  for  examination. 

A  larger  incision  may  be  made  in  the  scalp  and  a  larger  opening 
made  in  the  skidl  with  a  larger  burr  if  desired.  The  place  where 
the  aspiration  is  made  will  vary  according  to  the  location  of  the 
suspected  abscess,  cyst,  tumor,  etc. 

For  Tapping  the  Lateral  Ventricles. — ^The  needle  may  be 
introduced,  according  to  Keen,  at  a  point,  3  cm.  above  and  3  cm. 
behind  the  external  auditory  meatus.  The  needle  enters  the  posterior 
part  of  the  temporo-sphenoidal  lobe.  It  is  pushed  in  a  direction 
toward  the  toj)  of  the  pinna  of  the  ear  of  the  opposite  side.  The 
needle  enters  the  ventricle  at  a  depth  of  5  cm. 

According  to  Kocher  the  ventricle  is  entered  through  the  frontal 
lobe  at  a  point  just  anterior  to  the  bregma  and  2%  cm.  away  from 
the  middle  line.  The  needle  is  directed  downward  and  backward 
and  enters  the  ventricle  at  a  depth  of  5  to  6  cm. 

The  more  the  ventricle  is  distended,  the  easier  it  is  to  strike  it. 
The  amount  of  fluid  removed  is  governed  by  the  symptoms,  the  effect 
on  the  pulse,  blood-pressure,  etc. 

Permanent  Drainage  op  the  Lateral  Ventricles  (Krause). 
— Permanent  drainage  of  the  lateral  ventricles  may  be  established 
by  introducing  a  cannula  into  the  lateral  ventricle  and  fixing  the 
outer  end  of  the  cannula,  which  emerges  through  an  opening  in  the 
skull  in  such  a  manner  that  the  fluid  from  the  ventricle  is  able  to 
escape  continuously  through  the  cannula  into  the  loose  connective 
tissue  underneath  the  scalp. 

A  small  incision  is  made  in  the  scalp  down  to,  but  not  through 
the  periosteum.  The  periosteum  is  incised  and  detached  from  the 
surface  of  the  bone  on  either  side  of  the  incision  so  as  to  form  two 
little  pockets,  one  on  either  side,  between  the  periosteum  and  the 
bone.  A  hole  2  mm.  in  diameter  is  drilled  through  the  skull.  A 
flexible  silver  cannula,  2  mm.  in  diameter,  is  fitted  snugly  over  an 


OPERATIONS  UPON  THE  HEAD. 


99 


aspirating  needle.  Tlie  as})irating  needle  carrying  the  silver  cannula  is 
introduced  through  the  opening  in  the  skull  and  pushed  through 
the  substance  of  the  brain  until  fluid  is  reached.  The  asjHrating 
needle  is  then  withdrawn,  leaving  the  end  of  the  cannula  in  the  ven- 
tricle. The  cannula  is  withdrawn  a  little  and  then  again  pushed  in 
a  little  to  make  certain  that  the  end  presents  just  within  the  ven- 
tricle.    The  free   end  of  the  cannula  which  protrudes  through  the 


\  t')UH4%f^ 


Fig.  64.— Drainage  of  the  Lateral  Ventricle.     Cannula  in  the  lateral  ventricle  for 
continuous   drainage.     B,   skull;   P,   periosteum;    8,   scalp. 

opening  in  the  skull  is  cut  off  except  for  a  portion  about  1  cm.  in 
length.  The  protruding  portion  of  the  cannula  is  bitten  off,  without 
damaging  its  lumen,  in  the  following  manner:  A  hard-steel  stylet 
is  introduced  into  the  cannula  and  the  cannula  then  cut  off  w^ith 
the  scissors  at  the  desired  point.  The  stylet  within  the  cannula  forms 
a  hard,  resistant  countersurface  to  cut  upon,  and  prevents  the  walls 
of  the  cannula  from  being  crushed  together,  thus  interfering  with  its 
lumen.  The  stylet  is  withdrawn.  The  protruding  end  of  the  can- 
nula, about  1  cm.,  is  split  with  a  narrow-bladed  scissors  so  that  the 
two  split  portions  may  be  bent  back,  "T"  fashion,  against  the  sur- 


100  HEAD  AND  FACE. 

face  of  the  skull.  Tims  the  cannula  is  prevented  from  being  forced 
farther  into  the  brain  or  lost  within  the  cranial  cavity.  In  order 
to  prevent  the  cannula  from  coming  out  the  two  bent  arms  corre- 
s^Donding  to  the  split  end  of  the  cannula  are  fitted  into  the  two  little 
pockets  between  the  periosteum  and  the  surface  of  the  bone  that 
have  been  formed  by  detaching  the  former,  and  are  secured  thus  by 
suturing  the  edges  of  the  periosteum  together  just  above  and  just  be- 
low the  mouth  of  the  cannula.  Silk  sutures  are  used.  The  edges  of 
the  incision  in  the  scalp  are  united,  accurately  covering  over  the  end 
of  the  cannula  with  several  silk  sutures. 

There  may  be  a  little  leakage  through  the  incision  in  the  scalp 
for  a  few  days,  but  the  incision  in  the  scalp  finally  closes  over  the 
end  of  the  cannula  and  the  cerebro-spinal  fluid  is  thus  able  to  escape 
into  the  loose  tissue  under  the  scaljD,  where  it  is  absorbed.  There 
may  be  considerable  oedema  of  the  soft  parts,  head  and  face,  for  a 
few  days,  but  this  gradually  subsides. 

CEAisriECTOGMY  (LiNEAE  CRANIOTOMY). — Making  linear  furrows 
in  the  skull  for  the  purpose  of  providing  space  to  permit  of  the  proper 
growth  of  the  brain,  in  cases  of  microcephalia  and  idiocj^  It  is  very 
questionable  whether  operation  is  of  any  value. 

This  operation  was  first  performed  by  Lannelongue.  It  may  be 
done  on  one  or  both  sides  of  the  skull  at  one  sitting. 

A  longitudinal  incision  is  made  in  the  scalp  in  the  middle  line 
commencing  at  a  point  just  above  the  occipital  protuberance  and 
carried  forward  as  far  as  the  hair-line  of  the  scalp;  from  the  ante- 
rior end  of  this  a  second  curved  incision  may  be  made  reaching  down- 
ward and  outward  away  from  the  middle  line;  this  latter  incision 
is  also  placed  within  the  hair-line  of  the  scalp.  The  scalp  is  then 
raised  from  the  skull  with  the  elevator. 

Posteriorly,  just  above  the  occipital  protuberance,  an  opening  is 
made  in  the  skull  with  the  trephine,  about  one-half  inch  in  diameter, 
and  through  this  opening,  with  the  bone-forceps  (a  De  Vilbiss  or 
Hudson  bone  forceps  serves  the  purpose  very  satisfactorily),  a  furrow 
is  cut  which  is  carried  forward  to  within  an  inch  of  the  supra-orbital 
ridge.  This  channel  should  be  one-fourth  of  an  inch  wide  and  will 
vary  from  five  to  six  and  one-half  inches  in  length  and  should  be 
placed  about  three-fourths  of  an  inch  away  from  the  middle  line  in 
order  to  avoid  the  longitudinal  sinus.  The  dura  is  detached  from 
the  inner  surface  of  the  skull  to  permit  the  use  of  the  bone  forceps, 
but  it  should  not  be  incised. 


TREPHINING  OF  THE  FRONTAL  SINUS.  101 

From  either  end  of  tlic  longitudinal  furrow  in  the  bone  an  ad- 
ditional channel  may  be  cut,  reaching  downward  and  outward  for 
one  or  two  inches  away  from  the  middle  line. 

The  periosteum  is  cut  away  from  the  margins  of  the  furrows 
in  the  bone  to  prevent  reproduction  of  the  bone.  If  any  of  the  branches 
of  the  meningeal  are  injured  during  the  course  of  the  operation, 
they  may  be  surrounded  by  ligatures  carried  in  a  curved  surgeon's 
needle  and  tied.  It  is  often  difficult  to  secure  these  branches  with 
the  artery  forceps,  and  thus  the  necessity  of  carrying  the  ligatures 
around  them  in  the  needle. 

The  edges  of  the  incision  in  the  scalp  are  accurately  approxi- 
mated without  drainage,  to  insure  primary  healing. 

The  longitudinal  furrow  in  the  skull  is  usually  placed  to  the 
left  of  the  middle  line,  but  may  be  placed  upon  the  right  side  in- 
stead, if  this  appears  to  be  the  less  developed  side. 

Trephining  of  Frontal  Sinuses. — For  purpose  of  providing  drain- 
age in  cases  of  empyema.  A  curved  incision  commencing  in  the 
middle  line  above  the  root  of  the  nose  and  passing  outward  along  the 
upper  margin  of  the  orbit  corresponding  to  the  line  of  the  eyebrow. 
The  incision  passes  through  the  soft  parts,  including  the  periosteum 
down  to  the  bone.    The  bone  is  denuded  with  the  periosteum  elevator. 

The  anterior  bony  wall  of  the  sinus  is  penetrated  with  the  chisel 
and  mallet.  The  opening  is  placed  to  the  outer  side  of  the  middle 
line  and  above  the  margin  of  the  orbit.  The  mucous  lining  of  the 
sinus  which  is  thus  exposed  is  incised.  The  opening  in  the  bone  may 
be  enlarged  if  necessary  with  the  bone-forceps  or  chisel.  The  sinus 
may  be  curetted  with  the  sharp  spoon;  but  this  is  not  necessary  in 
all  cases.  A  probe  is  passed  into  the  sinus  and  down  through  the 
infundibulum  into  the  nasal  cavity.  This  passage  should  be  free  so 
as  to  permit  drainage.  The  infundibulum  takes  a  curved  course  from 
the  frontal  sinus  first  downward  and  somewhat  backward  and  then 
forward,  and  opens  under  the  front  portion  of  the  middle  turbinated 
bone.  Drainage  is  provided  by  drawing  a  tube  or  a  strip  of  gauze 
from  the  incision  down  through  the  infundibulum  and  out  through 
the  nose.  In  addition  the  sinus  is  loosely  packed  through  the  skin 
incision.  The  incision  is  closed  in  part.  If  both  sinuses  are  involved 
the  incision  can  be  carried  across  and  above  the  other  orl)it.  and  the 
sinus  of  that  side  also  opened  in  a  similar  manner  by  gouging  away  its 
front  wall.  The  septum  between  the  two  sinuses  is  broken  down  Avitli 
the  chisel. 


102  HEAD  AND  FACE. 

Ivillian's  Operation. — This  operation  is  performed  for  chronic 
suppuration  of  the  frontal  sinus.  It  consists  in  removing  the  an- 
terior wall  and  floor  of  the  frontal  sinus,  freely  curetting  the  sinus 
and  establishing  drainage  into  the  nasal  cavity.  A  bridge  of  bone, 
the  supra-orbital  margin,  is  left  for  cosmetic  effect  and  to  support 
the  soft  parts  and  prevent  falling-in  of  the  eyebrow. 

It  is  not  necessary  to  shave  the  eyebrows;  it  suffices  to  trim  the 
hairs  quite  short.     The  nasal  cavity  is  plugged  with  strip  gauze. 

The  incision  is  made  along  the  line  of  the  eyebrow,  hair-line, 
from  the  root  of  the  nose  outward  as  far  as  the  outer  end  of  the 
supra-orbital  margin.  From  the  root  of  the  nose  the  incision  is 
carried  downward  upon  the  side  of  the  nose  and  then  curved  out- 
ward, terminating  at  a  jDoint  about  one-half  inch  below  the  junction 
of  the  inner  and  middle  thirds  of  the  inferior  orbital  margin.  This 
incision  goes  clown  to,  but  does  not  include  the  periosteum.  The 
■edges  of  the  incision  are  retracted  with  sharp-pronged  retractors. 
Spurting  vessels  are  secured  with  hgemostats  and  ligated.  The  peri- 
osteum is  incised  along  a  line  parallel  with  and  about  one-quarter 
inch  above  the  supra-orbital  margin.  A  second  periosteal  incision 
commences  just  below  the  inner  end  of  the  supra-orbital  margin — 
just  inside  the  orbit — and  just  internal  to  the  point  where  the  pully  of 
the  superior  oblique  muscle  is  attached  to  the  roof  of  the  orbit,  and  is 
continued  inward  and  downward  along  the  line  of  the  corresponding 
part  of  the  skin  incision.  The  contents  of  the  orbit  are  held  away  and 
retracted  with  the  Killian  spatula.  With  the  periosteum  elevator  the 
periosteum  is  detached  from  the  surface  of  the  bone,  upward,  away 
from  the  supra-orbital  incision,  thus  denuding  the  surface  of  bone 
corresponding  to  the  anterior  wall  of  the  frontal  sinus,  and  doAvn- 
ward,  away  from  the  lower  periosteal  incision,  denuding  the  bone 
corresponding  to  the  inner  part  of  the  roof  of  the  orbit.  The  peri- 
osteum covering  the  bridge  of  bone  which  it  is  proposed  to  leave  to 
support  the  soft  parts  is  thus  left  undisturbed.  The  front  wall  of 
the  sinus  is  penetrated  with  a  chisel  and  mallet,  and  a  considerable 
opening  made  with  the  rongeur  bone-forceps.  The  mucous  membrane 
lining  of  the  sinus  is  freely  incised — it  is  at  times  found  very  much 
thickened — and  the  sinus  is  thus  entered.  The  interior  of  the  sinus 
is  explored  with  the  probe  to  discover  its  dimensions,  extent,  etc.,  and 
then  the  entire  contents  removed  with  the  sharp  curette.  The  floor 
of  the  sinus  is  perforated  with  the  chisel  and  mallet,  and  the  entire 
floor  of  the  sinus  then  gouged  away  with  the  rongeur  forceps,  working 


TREPHINING  OF  THE  FRONTAL  SINUS. 


103 


Fig.  65. — Frontal  Sinus.  Right  Side,  Simple  Operation;  Left  Side,  Killian 
Operation.  Shows  bridge  of  bone.  Probe  is  passed  under  bridge  of  bone  through 
Irom  opening  in  frontal  sinus  into  orbit. 


104  HEAD  AND  FACE. 

toward  the  front  and  downward  and  sacrificing  the  frontal  process 
of  the  superior  maxillary  bone.  The  anterior  ethmoidal  cells  are 
thus  freel}^  uncovered  and  may  be  curetted  if  diseased,  and  a  large 
opening  established  into  the  nasal  cavity  for  the  purpose  of  drainage. 
The  operation  may  be  continued  farther  if  conditions  warrant,  break- 
ing down  of  all  the  ethmoidal  cells,  removal  of  the  middle  turbinate, 
and  opening  and  curettage  of  the  sphenoidal  sinus.  A  biting  bone- 
forceps  of  the  Griining  type  is  used,  and  gTeat  care  must  be  exercised 
in  using  the  curette  and  other  instruments — especially  not  to  per- 
forate the  cribriform  plate  of  the  ethmoid  or  the  roof  of  the  sphenoidal 
sinus. 

The  posterior  cranial  wall  of  the  frontal  sinus  may  be  found 
necrosed,  and  it  may  be  necessary  to  remove  a  considerable  portion 
of  this  wall  with  the  rongeur,  exposing  the  dura. 

After  the  operation  has  been  completed  the  resulting  cavity  is 
wiped  dry  and  packed  with  strip  gauze.  The  first  end  of  the  gauze 
strip  is  passed  through  the  wound,  down  into  the  nasal  cavity,  so 
that  later  it  may  be  readily  seized  and  removed  through  the  nose. 
The  orbital  contents  are  gently  replaced  and  the  incision  very  ac- 
curately closed  with  interrupted  silk  sutures,  which  include  the  edges 
of  the  detached  periosteum.  The  entire  external  wound  is  thus 
closed  and  the  frontal  sinus  drains  into  the  nasal  cavity.  The  gauze 
packing  is  removed  and  replaced  after  two  or  three  days. 

For  Abscess  in  the  Frontal  Lobe.- — ^Abscess  of  the  frontal 
lobe  may  be  due  to  direct  infection  through  a  compound  fracture, 
penetrating  wound  of  the  skull;  or  it  may  occur  in  connection  with 
necrosis  and  chronic  suppuration  of  the  bones  of  the  front  part  of 
the  skull.  Most  commonly,  however,  abscess  of  the  frontal  lobe  is 
secondary  to  suppuration  in  the  air  sinuses  adjacent  to  the  nasal  cavity 
— the  frontal  sinuses,  ethmoidal  and  sphenoidal  sinuses. 

The  frontal  lobe  of  the  brain  may  be  exposed  through  the  frontal 
sinus  during  the  course  of  an  operation  upon  the  sinus;  or  sub- 
sequent to  such  an  operation  if  the  sjnnptoms  continue  and  point  to 
abscess  in  the  frontal  lobe.  The  posterior  wall  of  the  sinus  is 
gouged  away  until  an  opening  in  the  skull  sufficiently  large  has  been 
obtained.  If  abscess  of  the  frontal  lobe  occurs  independent  of 
frontal-sinus  infection,  an  opening  may  be  made  in  the  frontal  bone 
with  the  trephine  and  rongeur  forceps,  or  an  osteo-tegumentary  flap 
reflected  in  this  part  of  the  skull. 

After  the  dura  mater  has  been  incised  and  before  opening  the 


EXTIRPATION  OF  THE  GASSERIAN  GANGLION.  105 

abscess  the  subdural  space  should  be  packed  with  strip  gauze  if  the 
space  has  not  already  been  shut  off  by  adhesions  between  the  dura 
and  the  pia-arachnoid.  The  abscess  is  incised,  the  pus  evacuated, 
and  the  cavity  is  packed  with  strip  gauze.  The  abscess  cavity  is  not 
irrigated. 

THE   MIDDLE  FOSSA   OF  THE   SKULL. 

Extirpation  of  the  Gasserian  Gang^lion  (Hartley-Krause). — The 

operation  may  be  done  in  one  or  two  sittings.  The  patient  is  placed 
in  a  semirecumbent  position  with  the  head  turned  partly  to  one  side. 
A  horseshoe-shaped  flap,  consisting  of  the  integument  and  the  under- 
lying muscle  and  the  corresponding  segment  of  bone,  is  turned  down. 

The  incision  passes  through  the  whole  thickness  of  the  soft 
parts,  including  the  periosteum,  down  to  the  bone.  This  incision 
commences  anteriorly,  just  above  the  zygoma,  and  about  a  finger's 
breadth  behind  the  external  angular  process;  it  is  carried  upward 
upon  the  temporal  region  describing  an  arc,  its  posterior  limb  ter- 
minating just  in  front  of  the  tragus.  Bleeding  points  are  secured 
with  artery  forceps  and  ligatures.  The  flap  thus  marked  out  meas- 
ures in  its  vertical  diameter  three  inches,  about  two  inches  across 
its  widest  part,  and  from  one  and  one-half  to  two  inches  at  its  base, 
which  is  just  above  the  zygoma.  Corresponding  to  the  skin  incision 
a  groove  is  chiseled  all  around  in  the  bone.  The  Hartley  chisels  are 
probably  the  best  for  this  purpose,  as  they  cut  a  distinct  groove;  if 
an  ordinary  narrow  chisel  is  used,  it  should  be  held  quite  obliquely 
and  only  its  corner  engaged  in  the  bone  while  cutting.  Care  should 
be  taken  not  to  injure  the  dura  with  the  chisel.  The  bone  may  be 
cut  more  conveniently  and  with  less  danger  of  injuring  the  dura 
with  the  biting  bone-forceps — the  De  Vilbiss,  Hudson,  etc.,  or  with 
the  Gigli  saw,  as  described  on  page  86. 

The  elevator  is  introduced  as  a  lever  into  the  upper  part  of 
the  cut  in  the  bone  and  the  segment  of  bone,  with  the  soft  parts 
still  attached,  is  broken  through  at  its  base  and  turned  well  down 
over  the  zygoma;  if  the  opening  is  not  sufficiently  large,  more  bone 
may  be  cut  away  from  the  lower  margin  of  the  opening  with  the  bone 
forceps.  Through  this  opening  in  the  skull  the  dura  mater  is  ex- 
posed, the  anterior  branch  of  the  middle  meningeal  ramifying  upon 
it  toward  the  front;  at  times  this  branch  is  torn  when  the  plate  of 
bone  is  reflected,  especially  if  the  groove  in  the  bone  in  which  the 
vessel  is  lodged  is  unusually  deep;  if  injured,  it  should  be  ligated. 


106  HEAD  AND  FACE. 

Now,  with  the  fingers  or  the  blunt  periosteum  elevator,  the  dura  is 
separated  from  the  bone,  from  the  floor  of  the  middle  fossa.  This 
step  of  the  operation  may  be  executed  without  much  difficulty  until 
the  middle  meningeal  artery,  as  it  enters  the  skull  through  the  fora- 
men spinosum,  is  encountered.  When  this  vessel  is  exposed  it  should 
be  secured  with  a  double  catgut  ligature  and  divided.  If  difficulty 
is  experienced  in  ligating  the  artery,  or  if  it  is  torn  off  close  to  the 
foramen  through  which  it  enters  the  skull,  the  hemorrhage  may  be 
controlled  by  plugging  the  opening  with  a  wooden  peg  or  by  in- 
troducing a  Krause  hook  into  the  opening  and  twisting  it  within 
the  opening  until  the  bleeding  is  controlled.  The  field  of  operation 
is  kept  clear  of  blood  with  gauze  wipes  on  holders.  After  the  middle 
meningeal  artery  has  been  disposed  of  and  still  working  inward,  but 
rather  more  cautiously,  the  dura  mater  is  detached  from  the  base 
of  the  skull  with  a  blunt  elevator  or  with  a  small  gauze  pad  in  a 
forceps,  at  the  same  time  lifting  the  brain  away  from  the  base  of 
the  skull  toward  the  vault.  This  is  best  accomplished  with  the  aid 
of  a  narrow,  polished,  right-angle  retractor.  A  very  appropriate  in- 
strument for  the  purpose  is  shown  in  Fig.  66.  The  fiat,  fiexible  re- 
tractor is  also  very  useful.  The  blade  may  be  bent  at  any  angle 
desired.  With  these  instruments  the  brain  can  be  very  conveniently 
lifted  away  from  the  base  of  the  skull.  A  pad  of  gauze  may  be  inter- 
posed between  the  retractor  and  the  brain;  by  this  means  the  hem- 
orrhage may  be  very  much  diminished.  The  hemorrhage  caused  by 
separating  the  dura  mater  from  the  bone  is  sometimes  considerable. 
It  may  be  controlled  by  a  few  minutes'  pressure  with  a  gauze  pad  or 
by  shifting  or  withdrawing  the  retractor  for  a  few  minutes  and  allow- 
ing the  brain  to  drop  back  upon  the  surface  of  the  bone.  Thus 
gradually  working  inward  we  reach  the  third  division  of  the  fifth 
nerve,  which  may  be  seen  passing  out  of  the  skull  through  the  fora- 
men ovale.  This  trunk  is  seized  with  a  narrow  forceps  and  isolated 
as  far  back  as  the  ganglion;  it  serves  as  a  guide  to  the  ganglion. 
Without  cutting  this  trunk,  we  then  work  a  little  farther  inward, 
toward  the  middle  line,  until  we  meet  the  second  division  of  the 
nerve.  This  is  likewise  isolated  and  followed  backward  from  the 
foramen  rotundum  as  far  as  the  ganglion.  The  upper  surface  of  the 
ganglion  is  then  gradually  freed  from  the  dura.  While  the  work 
of  isolating  the  ganglion  is  being  accomplished  the  brain  should  be 
well  retracted :  lifted  away  from  the  base  of  the  skull.  The  ganglion 
can  be  separated  from  the  overlying  dura  with  a  blunt  periosteum 


EXTIRPATION  OF  THE  GASSERIAX  GANGLION. 


107 


elevator.  The  third  division  of  the  nerve  may  be  seized  and  pulled 
upon  as  a  guide  to  the  ganglion.  It  may  be  necessary-  to  cut  a  few 
connective-tissue  bands,  between  the  ganglion  and  the  dura,  with 
the  scissors,  and  in  doing  this  the  operator  may  accidentally  cut  into 
the  dura:  this  accident,  however,  is  of  no  serious  significance;  some 
cerebro-spinal  fluid  will   escape,   but,   according  to  Tiffany,   this   is 


Fig.  66. — Hartley-Krause  Operation.  Brain  within  the  dura  lifted  away  from 
floor  of  middle  fossa.  The  second  and  third  division  of  the  fifth  nerve 
exposed. 

rather  an  advantage.  There  may  be  considerable  hemorrhage  oc- 
casioned in  isolating  and  detaching  the  ganglion,  but  this  may  again 
be  controlled  by  pressure  with  the  gauze  pad  or  by  shifting  the  re- 
tractor or  allowing  the  brain  to  drop  back  in  place  upon  the  bone 
temporarily.  The  ganglion  should  be  freed  as  far  back  as  the  superior 
border  of  the  petrous  portion  of  the  temporal  bone,  so  that  the  oper- 
ator may  be  able  to  see  the  white  trunk  of  the  nerve  showing  beyond 
the  o-anglion.     Care  should  be  exercised  in  freeing  the  inner  part  of 


108  HEAD  AND  FACE. 

the  ganglion,  on  account  of  the  proximity  of  this  part  of  tlie  cavernous 
sinus  and  the  carotid  artery.  The  operator  should  finally  be  able 
to  raise  the  detached  ganglion  away  from  the  surface  of  the  bone 
upon  which  it  rests  with  the  periosteum  elevator.  Occasionally  this 
surface  of  bone  is  absent,  and  the  ganglion  is  then  separated  from  the 
carotid  artery  as  it  lies  in  its  canal  by  only  a  thin,  cartilaginous  or 
fibrous  layer;  therefore  one  should  avoid  any  roughness  during  this 
step  of  the  operation. 

'  The  ganglion,  being  finally  free  all  around,  is  seized  with  a  long, 
thin  artery  clamp,  and  in  doing  this  it  is  necessary  to  avoid  catching 
the  dura,  etc.,  at  the  same  time  in  the  grasp  of  the  forceps.  The  third 
and  second  divisions  of  the  nerve  are  then  cut,  either  with  a  long 
thin  scissors  or  with  a  tenotome  close  to  their  foramina;  in  cuttting 
the  third  division,  the  motor  branch  of  the  nerve  is  usually  divided 
at  the  same  time  with  it.  An  effort  should  be  made  to  avoid  cutting 
the  motor  branch  as  the  third  division  is  severed,  but  this  is  often- 
times difficult  and  in  many  cases  its  division  is  excusable.  When 
the  third  division  is  cut  there  may  be  considerable  venous  hemorrhage 
from  the  small  meningeal  branch  which  enters  the  skull  through  the 
foramen  ovale;  this  can  be  controlled  by  packing  temporarily  or  by 
shifting  the  retractor  or  by  allowing  the  brain  to  drop  back  for  a 
few  minutes  upon  the  base  of  the  skull. 

]^o  attempt  is  made  to  isolate  or  cut  the  first,  the  ophthalmic, 
division  of  the  nerve  on  account  of  the  danger  of  doing  damage  to 
the  third,  fourth,  or  sixth  nerve  and  to  the  cavernous  sinus,  and, 
besides,  this  branch  is  readily  torn  away  when  the  ganglion  is  twisted 
out.  This  branch  may,  however,  be  exposed  just  where  it  comes  off 
from  the  Gasserian  ganglion. 

After  the  second  and  third  division  of  the  nerve  have  been  sev- 
ered the  ganglion,  in  the  grasp  of  the  long,  narrow  forceps,  is 
slowly  twisted  free,  tearing  it  away  from  the  first  division  and  usuallj^ 
bringing  away  with  it  a  portion  of  the  trunk  of  the  nerve  for  a  greater  . 
or  less  distance  beyond  the  ganglion.  Should  the  cavernous  sinus  be 
torn,  the  hemorrhage  is  profuse,  but  this  can  be  controlled  by  tem- 
porarily packing  with  a  strip  of  gauze  and  allowing  the  brain  to 
droj)  back  into  place  upon  the  base  of  the  skull. 

The  bone  is  finally  replaced  and  the  incision  in  the  soft  parts 
closed  with  suture.  A  strip  of  gauze  is  introduced  through  the  pos- 
terior part  of  the  opening  in  the  skull  if  there  is  considerable  oozing. 

This  operation  may  be  followed  by  ulcer  of  the  cornea  or  con- 


EXTIRPATION  OF  THE  GASSERIAN  GANGLION. 


109 


junctivitis,  due  to  infection  or  the  entrance  of  dirt  which  is  not  ap- 
preciated by  the  patient  on  account  of  the  loss  of  sensation  in  tlie 
eye.  This  may  be  avoided  by  bandaging  the  eye  aseptically  or  sealing 
it  with  a  watch-crystal. 

Ptosis,  paralysis  of  the  muscles  of  the  eye,  etc.,  may  occur  as  a 
result  of  injury  to  the  third,  fourth,  and  sixth  nerves.  These  com- 
plications may  be  avoided  by  keeping  away  from  the  first  division  of 
the  fifth  nerve  and  the  immediately  adjacent  third,  fourth,  and  sixth 
nerves  during  the  course  of  the  operation. 


Fig.  67. — Zygomatic  Arch  Resected  (Cusliing).  Opening  in  lower  anterior 
part  of  temporal  fossa.  Dura  supporting  anterior  branch  of  middle  meningeal 
exposed.    B,  edge  of  opening  in  skull;  M,  cut  edge  of  temporal  muscle. 


The  operation  may  be  done  in  two  sittings :  first,  turning  down 
the  osteo-tegumentary  flap;  second,  exposure  and  removal  of  the 
ganglion. 

Method  of  Cushixg. — ^The  zygomatic  arch  is  divided  and  dis- 
located downward  and  the  ganglion  is  approached  through  an  opening 
made  in  that  portion  of  the  great  wing  of  the  sphenoid  that  forms 
the  lower,  forward  part  of  the  temporal  fossa.  It  is  not  necessary  to 
divide  or  ligate  the  meningeal  artery  in  this  operation. 

A  horseshoe-shaped  incision  is  made  upon  the  side  of  the  head; 
its  base,  4  cm.  long,  corresponds  to  the  zygoma;  its  arch  reaches 


110  HEAD  AND  FACE. 

upward  for  a  distance  of  about  5  cm.;  the  highest  part  of  the  in- 
cision is  jnst  above  the  pinna  of  the  ear.  Tlie  flap  of  skin  and  fat  is 
detached  and  reflected  downward  below  the  level  of  the  zj'goma,  in  this 
way  exposing  the  fascia  covering  the  temporal  muscle.  Concentric  to 
and  just  inside  the  skin  incision,  the  temporal  fascia  is  divided.  The 
periosteum  corresponding  to  the  outer  surface  of  the  zygomatic  arch 
is  incised  and  peeled  off  the  bone,  leaving  the  attachment  of  the 
masseter  to  its  under  surface  intact  and  the  arch  then  divided  with 
bone-forceps  or  Gigli  saw,  both  anteriorly  and  posteriorl}'^,  and  dis- 
located downward.  Again,  corresponding  to  and  inside  the  skin  in- 
cision, the  temporal  muscle  is  incised  and  detached  downward  away 
from  the  surface  of  the  bone. 

A  small  opening  is  made  in  the  bone  in  the  lower  anterior  part 
of  the  temporal  fossa,  and  this  is  enlarged  with  the  rongeur  forceps 
until  an  opening  3  cm.  in  diameter  is  obtained.  The  dura  mater  sup- 
porting the  middle  meningeal  artery  is  thus  exposed,  the  artery  passing 
obliquely  forward  and  upward  across  the  opening  in  the  skull. 

The  dura  with  the  artery  uninjured  is  raised  away  from  the  base 
of  the  middle  fossa,  working  inward  with  the  elevator  until  the  loca- 
tion of  the  foramen  ovale  is  reached.  In  this  situation  the  dura  is 
found  more  fimnly  attached  to  the  bone.  The  dura  mater  envelope 
underneath  which  the  ganglion  and  its  three  intra-cranial  branches 
are  lodged  is  split  or  detached,  working  from  before  backward,  from 
the  region  of  the  foramen  rotundum  to  the  foramen  ovale,  continuing 
imtil  the  three  trunks  and  the  ganglion  back  as  far  as  its  sensory  root 
are  exposed.  With  the  periosteum  elevator  the  ganglion  and  the  three 
branches  are  detached  from  their  bed.  After  the  second  and  third 
trunks,  the  superior  and  inferior  maxillary  branches,  have  been  sepa- 
rated the  operator  proceeds  to  separate  the  first,  the  ophthalmic 
branch.  This  is  the  innermost  of  the  three  and  lies  in  close  relation 
with  the  cavernous  sinus  and  the  sixth  nerve.  The  separation  of 
this  branch  is  commenced  behind  the  ganglion  near  the  sensory  root, 
working  fon^^ard  with  the  elevator  and  avoiding  the  cavernous  sinus 
and  the  sixth  nerve.  Finally  the  ganglion  and  the  three  trunks  can 
be  lifted  free  upon  the  elevator. 

The  ganglion  is  grasped  behind  near  its  sensory  root  with  a 
long,  thin  forceps  and  raised  up  out  of  its  bed,  and  the  three  branches 
are  then  cut  close  to  their  foramina,  etc.,  and  the  ganglion  and  sensory 
root  twisted  free,  bringing  the  ganglion,  the  three  divisions  of  the 
nerve,  and  part  of  the  sensor}-  root  away  in  the  grasp  of  the  forceps. 


EXTIRPATION  OF  THE  GAS8ERIAN  GANGLION. 


Ill 


The  soft  parts  are  sutured  back  in  place;  it  is  unnecessary  to 
wire  the  detached  piece  of  zygoma.  The  eye  is  protected  with  a  sheet 
of  gutta  percha  and  dressings  applied.  As  a  rule,  it  is  not  necessaiy 
to  make  any  provision  for  drainage. 

Extirpation  of  the  Gasserian  Ganglion  (Rose- Andrews). — The 
incision   commences   at   a   point   near  the   external   angular   process, 


Fig.  68. — Resection  of  tlie  Gasserian  Ganglion,  etc.  KL,  Kronlein-Liicke 
incision;  RA,  Rose-Andrews  Incision.  Dotted  lines  represent  the  lines  of 
division  through  the  bones;   drill  holes  for  subsequent  wiring  of  the  fragments. 


curving  backward  above  the  zygoma  to  a  point  just  in  front  of  the 
ear,  whence  it  extends  downward  to  near  the  angle  of  the  jaw.  This 
incision  penetrates  through  the  skin  and  fat  only,  and  pains  should 
be  taken  to  avoid  injuring  the  parotid  gland,  Stenson's  duct,  and 
the  facial  nerve.  The  temporal  artery,  as  it  ascends  in  front  of  the 
ear,  may  be  divided,  in  which  case  it  will  be  necessary  to  ligate  it. 
The  flap  which  is  thus  outlined  is  reflected  downward  sufficiently  to 


112  HEAD  AND  FACE. 

expose  the  zygomatic  arch.  The  temporal  fascia  is  incised  along  the 
upper  border  of  the  zygomatic  arch. 

The  next  step  of  the  operation  is  the  division  of  the  zygomatic 
arch  with  the  G-igli  saw^  both  in  front  and  behind^  and  the  segment 
of  bone  which  is  thus  resected,  together  with  the  attached  masseter 
muscle,  is  then  reflected  downward.  Before  dividing  the  zygomatic 
arch  holes  should  be  drilled  through  the  bone  corresponding  to  the 
intended  line  of  section,  so  that  it  may  be  wired  back  in  place  after 
the  operation  has  been  completed.  When  this  flap,  including  the  de- 
tached segment  of  the  zygomatic  arch  and  the  masseter  muscle,  is 
turned  down,  the  coracoid  process  of  the  lower  jaw  and  the  tendon 
of  the  temporal  muscle,  which  is  attached  to  it,  are  exposed.  The 
coracoid  process  is  divided,  first  drilling  holes  for  subsequent  wiring, 
and,  together  with  the  attached  tendon  of  the  temporal  muscle,  this 
is  turned  upward.  There  is  now  exposed  the  internal  maxillary  artery 
passing  from  below,  forward,  and  upward  across  the  outer  surface 
of  the  external  pterygoid  muscle.  This  vessel  is  tied  double  and  di- 
vided. With  the  periosteum  elevator  the  external  pterygoid  muscle 
is  separated  from  its  attachment  to  the  under  surface  of  the  great 
wing  and  from  the  outer  surface  of  the  external  pterygoid  plate  of 
the  sphenoid.  All  hemorrhage  should  be  controlled  by  ligature  or 
pressure  as  the  operation  progresses  step  by  step.  With  the  finger 
in  the  wound  the  sharp  edge  of  the  external  pterygoid  plate  is  felt 
for  and  recognized  and,  tracing  this  upward  as  a  guide,  we  feel  or  see 
the  foramen  ovale  at  its  base  (see  Fig.  74). 

A  trephine  of  small  diameter  is  applied  to  the  base  of  the  skull 
(to  the  portion  corresponding  to  the  under  surface  of  the  great  wing 
of  the  sphenoid  which  has  been  laid  bare  by  detaching  the  external 
pterygoid  muscle)  anterior  and  a  little  external  to  the  foramen  ovale, 
and  here  a  small  button  of  bone  is  removed.  After  this  button  of  bone 
has  l>een  removed  the  bridge  of  bone  remaining  between  the  trephine 
opening  and  the  foramen  ovale  is  cut  away  with  a  rongeur  bone-forceps. 
The  third  division  of  the  fifth  nerve  is  seized  with  a  hook  and  drawn 
out  through  the  opening  in  the  skull  to  serve  as  a  guide  to  the  Gas- 
serian  ganglion,  and  then  the  second  division  of  the  nerve  is  also  seized 
with  the  hook  and  pulled  out  through  the  same  opening.  These  trunks 
are  both  divided  and  used  as  guides  to  the  ganglion,  which  lies  in  a 
direction  backward  and  inward  from  the  foramen  ovale,  within  the 
skull,  upon  the  apex  of  the  petrous  portion  of  the  temporal  bone.  The 
cut  ends  of  the  nerves,  still  attached  to  the  ganglion,  are  steadied  in  the 


SURGICAL  ANATOMY  OF  THE  MASTOID  REGION.  II3 

grasp  of  a  long,  narrow  artery  forceps,  and  with  a  curette  which  is 
introduced  through  the  opening  in  the  skull,  the  ganglion  is  destroyed 
and  scooped  out. 

The  technique  of  this  operation  is  difficult,  as  it  is  almost  im- 
possible to  reach  the  ganglion.  There  is  liability  to  profuse  hemor- 
rhage which  may  be  extremely  difficult  to  control  and  also  to  injury  of 
the  Eustachian  tube.  If  the  Eustachian  tube  is  injured  during  the 
course  of  the  operation,  the  danger  of  infection  is  great.  Oozing  can 
be  stopped  by  pressure  with  a  gauze  pad.  When  the  operation  has 
iDeen  finished,  the  parts  are  replaced,  the  coracoid  process  being  wired 
to  the  ramus  of  the  jaw  and  the  detached  segment  of  the  zygomatic 
.arch  fixed  in  place  with  wire  sutures.  The  incision  in  the  skin  is 
closed  with  a  sufficient  number  of  silk  sutures. 

THE  MASTOID  REGION  AND  THE  EAR. 

The  mastoid  region  and  the  ear  are  intimately  associated  with 
-each  other  clinically. 

The  Surgical  Anatomy  of  the  Mastoid  Region. — The  mastoid 
region  is  that  part  of  the  skull  which  corresponds  to  the  mastoid 
portion  of  the  temporal  bone. 

The  integument  of  this  region  is  thin  and  contains  very  little 
tat;  its  blood-supply  is  derived  from  the  posterior  auricular  artery, 
which  ascends  just  behind  the  ear.  This  vessel  lies  just  anterior  to 
the  line  of  incision  which  is  usually  made  for  operations  upon  the 
mastoid  antrum.  The  occipital  artery  ascends  beneath  the  tendon  of 
ihe  sterno-mastoid  muscle  and  becomes  superficial  midway  between  the 
mastoid  process  and  the  external  occipital  protuberance,  whence  it 
is  continued  upward  upon  the  back  of  the  skull. 

The  surface  of  the  mastoid  is  uneven  and  perforated  by  a  variable 
number  of  small  vascular  openings,  i^t  the  back  part  of  the  mastoid 
portion,  at  or  just  in  front  of  the  suture  line  between  it  and  the 
occipital  bone,  there  is  an  opening,  the  mastoid  foramen.  Through 
this  a  small  vein  passes  into  the  lateral  sinus  and  a  small  arterial 
branch  from  the  occipital  artery  to  the  dura  mater. 

The  inner  surface  of  the  mastoid  portion  presents  a  wide  groove, 
curving  from  above  downward  with  the  convexity  forward,  which 
lodges  the  sigmoid  (lateral)  sinus.  This  groove  is  located  about  half 
an  inch  behind  the  posterior  border  of  the  external  auditory  meatus, 
.and  presents  the  opening  of  the  mastoid  foramen. 


114  HEAD  AND  FACE. 

The  mastoid  portion  is  prolonged  below  in  a  teat-like  process, 
the  mastoid  process.  The  mastoid  process  is  larger  in  muscular  sub- 
jects; it  is  comparatively  small  in  the  child.  The  structure  of  this 
process  varies.  Its  cortex  may  be  thin  or  may  be  thick  and  very  hard 
like  ivory.  The  mastoid  process  is  usually  made  up  of  a  number  of 
cellular  spaces,  the  pneumatic  mastoid,  all  lined  with  mucous  mem- 
brane and  communicating  through  the  antrum  with  the  middle  ear 
(tympanum) ;  these  reach  to  the  tip  of  the  process  and  often  penetrate 
beyond  the  limits  of  the  mastoid  process  into  the  occipital  bone  or 
zygomatic  process  or  they  may  extend  backward  into  the  mastoid 
portion  proper,  pretty  close  to  the  groove  which  lodges  the  sigmoid 
sinus,  so  that  there  may  be  but  a  very  thin  shell  of  bone  separating 
the  mastoid  cells  from  the  sinus.  Mastoids  vary  in  different  people 
and  upon  opposite  sides  in  the  same  person  as  to  the  extent  to  which 
these  cells  are  developed.  They  begin  to  develop  early  in  life,  but  the 
age  differs  at  which  they  are  found  fully  developed.  From  five  years 
on  they  are  fairly  well  marked,  and  it  is  said  that  at  the  age  of 
fifteen  years  they  are  all  developed  down  to  the  tip  of  the  process. 
Some  say  that  they  do  not  reach  complete  development  until  a  few 
years  later.  The  cellular  spaces  are  all  lined  with  mucous  membrane 
and  communicate  with  each  other,  and,  through  the  antrum,  with 
the  middle  ear.  The  mastoid  process  may  be  composed  of  ordinary 
spongy  bone,  or  it  may  be  found  occasionally  very  dense  and  hard, 
resembling  ivory.  Occasionally  the  bone  undergoes  a  process  of  rare- 
faction, the  septa  gradually  disappearing  and  the  spaces  opening  into 
one  another  until  they  are  all  combined  in  one  large  space  represented 
by  the  antrum.  There  is  always  present,  even  in  the  newborn,  at  least 
one  space, — the  antrum. 

The  mastoid  antrum  is  a  space  varying  in  size  from  a  small  pea 
to  a  small  bean,  which  is  found  in  the  mastoid  process  just  behind 
and  above — on  a  higher  level  than — the  tympanic  cavity.  The  mastoid 
antrum  communicates  with  the  tympanic  cavity  through  an  opening 
in  the  upper  part  of  the  posterior  wall  of  the  tympanum, — the  iter 
or  aditus  ad  antrum.  This  passage  is  partly  occupied  by  the  ossicles. 
The  roof  of  the  antrum  is  formed  by  the  same  plate  of  bone  that  forms 
the  roof  of  the  tympanic  cavity.  The  antrum  is  lined  with  mucous 
membrane  which  is  continuous  with  that  of  the  tympanum.  The 
antrum  is  practically  a  part  of  the  tympanic  cavity  and  an  inflam- 
matory process  originating  in  the  tympanum  may  very  readily  extend 
and  involve  the  antrum  and  adjacent  air  spaces  in  the  mastoid  process. 


SURGICAL  ANATOMY  OF  THE  MASTOID  REGION. 


115 


In  the  adult  the  mastoid  antrum  is  found  at  a  depth  of  from  12  to 
18  mm.  (1/2  to  %  inch)  beneath  the  external  surface  of  the  bone. 
The  position  of  the  antrum  corresponds  externally  to  the  small  tri- 
angular depression  which  is  found  just  behind  the  posterior  margin 
of  the  external  auditory  meatus.     This  little  triangular  space  is  called 


Fig.  69. — Side  of  Skull.  A,  position  of  opening  in  skull  to  expose  the  ante- 
rior branch  of  the  middle  meningeal  (Vogt's  lines) ;  O,  position  of  opening  for 
cerebellar  abscess;  MA,  location  of  mastoid  antrum  (directly  in  front  of  circle 
MA  is  the  spina  supra  meatum);  P,  opening  to  expose  the  posterior  branch 
of  middle  meningeal;  i?,  Reid's  base-line  continued  backward  to  external 
occipital  protuberance;  »S,  dotted  lines  represent  course  of  lateral  (sigmoid) 
sinus;   TS,  opening  in  the  skull  for  abscess  of  the  temporo-sphenoidal  lobe. 

the  jossa  ma-stoidea.  It  is  bounded  above  by  the  line  that  marks 
the  posterior  root  of  the  zygoma^  anteriorly  by  the  posterior  margin 
of  the  external  auditory  meatus;  the  third  side  of  the  triangle  may 
be  supplied  by  drawing  a  tangent  upward  and  backward  from  the 
lower  posterior  portion  of  the  margin  of  the  external  auditory  meatus. 
The  posterior  margin  of  the  external  auditory  meatus  is  marked  above 


116  HEAD  AND  FACE. 

by  a  spine,  the  spina  supra  meatiim,  or  spine  of  Henle.  This  spine 
is  readily  recognized  after  the  soft  parts  have  been  incised  and  sep- 
arated from  the  bone,  and  is  a  very  useful  landmark  in  locating  the 
level  of  the  antrum,  etc. 

In  very  young  children  the  antrum  is  comparatively  large  and 
very  close  to  the  surface  of  the  bone,  just  behind  the  upper  part 
of  the  posterior  margin  of  the  external  auditory  meatus. 

The  Anatomy  of  the  Ear. — Changes  that  occur  in  the  first 
visceral  cleft  result  in  the  formation  of  the  external  and  middle  ear. 
The  internal  ear,  lab5rrinth,  etc.,  are  formed  within  the  substance  of 
the  petrous  portion  of  the  temporal  bone.  The  external  fossa,  or  cleft, 
develops  into  the  external  auditory  canal  and  auricle;  the  internal 
fossa,  or  cleft,  which  opens  into  the  pharynx,  becomes  the  Eustachian 
tube  and  tympanum.  Where  the  funduses  of  these  clefts,  or  fossae, 
meet,  their  walls  coalesce  and  thus  form  the  drum,  the  partition  be- 
tween the  external  and  the  middle  ear.  The  margin  of  the  outer 
opening  of  the  external  cleft,  or  fossa,  becomes  thickened  and  nodu- 
lated, and  these  nodules,  coalescing,  form  the  external  ear. 

The  hearing  ajDparatus  may  be  divided  into  the  external  ear, 
which  includes  the  auricle  (pinna),  external  auditory  canal,  and 
drum;  the  middle  ear,  tympanum,  which  communicates  with  the 
pharynx  through  the  Eustachian  tube ;  and  the  internal  ear,  labyrinth, 
etc.,  inclosed  within  the  petrous  portion  of  the  temporal  bone. 

The  auricle  is  made  up  of  a  cartilaginous  plate  considerably 
folded  upon  itself  and  covered  with  skin;  it  consists  of  several  parts. 
It  is  attached  to  the  side  of  the  head  by  ligamentous  bands;  one  of 
these  passes  forward  to  the  root  of  the  zygolna;  the  other  backward 
to  the  mastoid  process.  Its  blood-supply  is  derived  from  branches 
which  are  given  off  by  the  temporal  artery  in  front  and  the  posterior 
auricular  behind.  The  supply  is  very  abundant,  and  therefore  wounds 
of  the  ear  heal  kindly. 

The  external  auditory  canal  is  about  one  inch  (24  mm.  Trolsch) 
in  length;  its  outer  portion,  comprising  one-third  of  its  length,  is 
cartilaginous  and  continuous  with  the  auricle;  the  inner  part,  com- 
prising two-thirds  of  its  length,  is  bone.  The  course  of  the  canal  is 
transverse,  but  it  suffers  two  curves:  one,  in  its  cartilaginous  part, 
with  its  convexity  forward;  the  second  at  the  junction  of  the  carti- 
laginous and  bony  parts,  with  its  convexity  backward;  this  junction 
is  the  narroAvest  part  of  the  canal,  and  is  called  the  isthmus. 

To  expose  the  drum,  the  auricle  is  drawn  uj)ward,  backward,  and 
outward  awav  from  the  side  of  the  head. 


ANATOMY  OF  THE  EAR.  117 

In  the  newborn  child  tliere  is  no  bony  portion  to  the  external 
auditory  canal,  this  part  being  represented  only  by  a  ring  of  bone 
into  which  the  drmn  is  fitted.  This  bony  ring,  the  auditory  process, 
is  incomplete,  and  is  applied  against  the  depressed,  hollowed-out  under 
surface  of  the  squamous  portion  of  the  temporal,  which  thus  completes 
the  ring.  At  this  early  age  the  drum  is  very  near  the  surface  of  the 
body,  there  being  no  depth  to  the  bony  auditor}'  canal.  As  the  child 
grows,  the  bony  ring,  the  auditory  process,  broadens  out,  and  in  the 
adult  is  represented  by  the  external  auditory  process,  which  corre- 
sponds to  its  outer  edge,  and  by  the  vaginal  process,  this  latter  form- 
ing the  lower  and  anterior  wall  of  the  bony  portion  of  the  auditory 
canal  and  the  back  part  of  the  floor  of  the  glenoid  cavity.  The  upper 
wall  of  the  auditors-  canal  is  formed  bv  the  grooved  under  surface 


Short  process  of  the  malleus. 

-  Long  process  of   the   incus. 

-  Handle  of  the  malleus. 


Fig.  70. — Right  Membrana  Tympani  Viewed 
through  the  Auditory  Canal. 

of  the  squamous  portion  of  the  temporal  bone.  The  outer  edge  of 
the  auditory  process  is  rough  and  the  upper  posterior  angle  presents 
a  spine,  usually  well  marked, — the  spina  supra  meaiuvi,  or  spine  of 
Henle.  The  cartilaginous  part  of  the  auditory  canal  is  attached  to  the 
rough  outer  edge  of  the  external  auditor}'  process  by  fimi  bands  of 
connective  tissue. 

The  skin  which  lines  the  interior  of  the  auditory  canal  is  con- 
tinuous with  that  which  covers  the  surface  of  the  dnim. 

The  bony  part  of  the  external  auditory  canal  is  in  relation,  above, 
with  the  middle  fossa  of  the  skull,  from  which  it  is  separated  by  a 
thin,  cellular  plate  of  bone,  part  of  the  squamous  portion  of  the 
temporal;  behind,  it  is  in  relation  with  the  mastoid  system  of  cells, 
and,  in  front,  with  the  condyle  of  the  lower  jaw  and  the  parotid 
gland. 

Blows  upon  the  chin  may  be  transmitted  through  the  lower  jaw 
to  the  condyle,  and  in  this  way  may  injure  the  auditor}-  canal,  so  that 
there  may  be  an  issue  of  blood  from  the  external  auditory  meatus. 


118  HEAD  AND  FACE. 

Purulent  processes  involving  the  auditory  canal  may  present  cerebral 
complications,  especially  in  children,  without  the  middle  ear  being 
involved,  the  infecton  in  these  cases  passing  through  the  roof  of  the 
auditory  canal  directly  into  the  cavity  of  the  skull. 

The  drum  is  the 'septum  between  the  external  and  the  middle 
ears.  It  is  made  up  of  skin  externally,  and,  internally,  of  the  mu- 
cous membrane  of  the  tympanum;  interposed  between  those  two  is 
a  layer  of  connective  tissue.  The  drum  is  set  in  a  bony  ring,  and 
forms  the  greater  part  of  the  external  wall  of  the  tympanum.  It  is 
set  obliquely  and  in  such  a  way  that  its  outer  surface  looks  down- 
ward, forward,  and  outward;  the  anterior  wall  of  the  external  audi- 
tory canal  is  thus  longer  than  the  upper,  posterior  wall. 

The  drum,  viewed  through  the  external  auditory  canal,  is  grayish 
in  color.  At  the  upper  anterior  part,  close  to  the  periphery,  is  a  whitish 
point  corresponding  to  the  position  of  the  short  process  of  the  malleus. 
Passing  downward  and  backward  from  this  point  is  a  slight  elevation 
corresponding  to  the  handle  of  the  malleus.  The  handle  of  the  mal- 
leus is  firmly  attached  to  the  inner  surface  of  the  drum,  and  tends  to 
draw  it  inward,  thus  presenting  a  concave  surface  to  the  auditory 
canal.  The  deepest  part  of  this  surface  corresponds  to  the  lower  end 
of  the  handle  of  the  malleus  and  is  called  the  umbo  menibran<E.  The 
long  process  of  the  incus  may  be  seen  posterior  to  the  upper  part  of  the 
handle  of  the  malleus  if  the  drum  is  quite  transparent.  A  line  continued 
downward  and  backward  in  the  direction  of  the  handle  of  the  malleus, 
and  another  line  drawn  at  right  angles  to  the  former  and  upon  a 
level  with  the  umbo,  serve  to  divide  the  drum  into  four  quadrants. 
Paracentesis  of  the  drum  is  performed  in  the  lower,  posterior  quadrant. 

The  Middle  Ear  consists  of  the  tympanum  and  adjoining  air- 
cells  and  the  Eustachian  tube. 

The  tympanum  is  a  wedge-shaped  cavity  separated  from  the  ex- 
ternal auditory  canal  by  the  drum  and  communicating  by  an  opening 
in  its  anterior  end,  through  the  Eustachian  tube,  with  the  pharynx. 
In  the  anterior  part  is  also  seen  the  Glaserian  fissure,  through  which 
the  middle  ear  communicates  with  the  glenoid  cavity  and  through 
which  the  chorda  tympani  leaves  the  t^^mpanum.  The  upper  part 
of  the  tympanum,  the  portion  above  the  level  of  the  membrana 
tympani,  is  called  the  attic.    In  this  space  the  ossicles  are  lodged. 

The  carotid  artery,  surrounded  by  a  venous  plexus,  traverses  a 
canal,  in  the  temporal  bone,  which  is  located  just  in  front  of  the 
tympanum  and  which  is  separated  from  this  cavity  by  a  very  thin 


AXATOMY  OF  THE  EAR. 


119 


C-^^^W^"^  ^ 


120  HEAD  AND  FACE. 

plate  of  bone  that  is,  at  times,  perforated.  Behind,  the  tympanum 
commimicates  with  the  mastoid  antrum  through  a  short  passage  in 
the  upper  part  of  its  posterior  wall,  called  the  iter  or  aditus  ad  antrum. 
The  roof  of  the  aditus  is  formed  by  the  same  thin  plate  of  bone,  tegmen 
t}Tiipani,  that  forms  the  roof  of  the  tympanum  and  the  antrum.  The 
aditus  is  partly  occuj)ied  by  the  body  of  the  incus  and  the  head  of  the 
malleus.  The  inner  wall  of  the  aditus  presents  an  eminence  of  bone 
corresponding  to  the  external  semicircular  canal.  Just  below  and  in 
front  of  this  there  is  a  second,  smooth,  cur^^ed,  linear  elevation  of  bone 
corresponding  to  that  part  of  the  aqugeductus  Fallopii,  which  arches 
backward  and  downward  over  the  foramen  ovale.  The  wall  of  the  aque- 
duct may  be  thin  or  absent,  and  the  facial  nerve  which  is  contained 
within  it  may  thus  readily  become  affected  in  inflammation  of  the  mid- 
dle ear.  The  aditus  will  permit  the  passage  of  a  probe  about  %  cm.  in 
diameter.  Inflammatory  processes  originating  in  the  t5^mpanum  may 
readily  extend  to  the  mastoid  antrum  through  the  aditus  ad  antrum. 
The  passage  may  become  blocked  by  swelling  of  the  mucous  mem- 
brane, and  the  presence  of  granulation  tissue,  and  drainage  from  the 
antrum  into  the  t3Tiipanum  may  be  thus  seriously  interfered  with. 
Purulent  material  imprisoned  in  the  antrum  may  cause  necrosis  of 
the  bone  and  may  spread  to  the  sigmoid  sinus  or  through  the  thin 
plate  of  bone  that  forms  the  roof  of  the  antrum  into  the  cranial  cavity. 
The  inner  wall  of  the  tympanum,  that  opposite  the  drum,  presents, 
toward  the  front,  the  promontory;  behind  this,  two  openings,  one 
above,  the  foramen  ovale,  and  another  below  and  a  little  behind,  the 
foramen  rotundum.  The  labjTinth  is  located  beneath  the  inner  wall, 
in  the  petrous  portion  of  the  temporal  bone.  This  inner  wall  presents 
a  smooth,  curved  ridge  above  the  foramen  ovale  which  runs  backward 
and  downward  toward  the  back  of  the  tympanum;  it  corresponds 
to  the  position  of  the  Fallopian  canal  which  lodges  the  facial  nerve 
in  its  course  through  the  petrous  portion  of  the  temporal  bone.  The 
layer  of  bone  which  separates  the  nerve  from  the  cavity  of  the  tym- 
panum is  sometimes  very  thin  or  perforated.  The  tympanum  com- 
municates with  the  posterior  fossa  of  the  skull  through  the  labyrinth 
and  the  internal  auditor}^  canal,  which  is  traversed  by  the  facial  and 
auditor}'-  nerves.  The  bulb  of  the  jugular  vein  is  lodged  in  the  de- 
pression in  the  temporal  bone  beneath  the  floor  of  the  tympanum. 
The  laj^er  of  bone  which  forms  the  floor  of  the  tympanum  is  usually 
comparatively  thick,  though  it  may  be  very  thin,  perforated,  or  en- 
tirely absent.     In  the  latter  case  the  mucous  membrane  lining  the 


ANATOMY  OF  THE  EAR.  121 

floor  of  the  tympanum  and  the  wall  of  the  internal  jugular  vein 
would  be  in  direct  contact  with  each  other.  Through  small  openings 
in  the  floor  of  the  tympanum,  Jacobson's  nerve,  a  branch  from  the 
glosso-pharyngeal,  and  some  small  arterial  and  venous  branches  enter 
the  tympanum. 

The  roof  of  the  tympanum,  the  most  common  link  between  dis- 
ease of  the  ear  and  intracranial  complications,  is  a  thin,  cellular 
plate  of  bone;  it  may  be  very  thin,  perforated,  or  entirely  absent. 
This  plate  of  bone  reaches  from  the  petrous  portion  of  the  temporal 
bone  over  to  the  inner  surface  of  the  squamous  portion,  where  a  suture 
line,  petroso-squamous,  exists.  In  the  child  this  suture  line  is  open 
and  contains  a  process  of  dura  mater  which  joins  with  the  mucous 
membrane  lining  of  the  tympanum  and  carries  blood-vessels  which 
take  part  in  the  supply  of  both  these  membranes.  This  condition, 
although  not  so  visible,  continues  to  exist  in  the  adult.  This  same 
thin  layer  of  bone,  which  forais  the  roof  of  the  t\Tnpanum,  reaches 
backward  and  forms  also  the  roof  of  the  mastoid  antrum.  The  roof 
of  the  tympanum  and  antrum  forms  part  of  the  floor  of  the  middle 
fossa  of  the  skull,  and  is  in  relation  with  the  dura  mater,  etc.,  and 
with  the  temporo-sphenoidal  lobe  of  the  brain. 

The  course  of  the  facial  nerve  through  the  temporal  bone  and 
its  relation  to  the  tympanum  and  the  mastoid  antrum  are  important. 
The  nerve  enters  the  internal  auditory  canal  in  company  with  the 
auditor}'  nerve,  and  passes  in  a  direction  forward  and  outward,  reach- 
ing the  inner  wall  of  the  middle  ear,  tympanum,  just  above  the  fora- 
men ovale:  here  it  makes  a  turn  and  runs  backward  and  downward 
in  the  aqu^eductus  Fallopii.  The  course  of  this  canal  is  indicated 
by  a  prominent  linear  elevation  upon  the  inner  wall  of  the  tympanum 
just  above  the  foramen  ovale ;  at  the  back  of  the  tympanum,  the  nerve, 
as  it  curves  downward  and  still  contained  within  the  aqu^ductus 
Fallopii,  is  situated  but  a  short  distance  in  front  of  the  antrum.  It 
continues  its  course  through  the  substance  of  the  petrous  portion  of 
the  temporal  bone,  emerging,  externally,  upon  the  base  of  the  skull, 
through  the  stylo-mastoid  foramen.  This  foramen  is  located  internal 
to,  and  a  little  in  front  of,  the  base  of  the  mastoid,  process.  Just 
before  the  facial  nerve  emerges  from  the  stylo-mastoid  foramen  and 
while  still  contained  within  the  canal,  it  gives  off  a  branch,  the  chorda 
t}Tnpani,  which  passes  forward  and  upward  through  a  separate  canal 
in  the  petrous  portion,  and  enters  the  tympanum  through  an  opening 
in  its  posterior  wall,  near  the  drum ;  it  runs  forward  through  the 


123  HEAD  AND  FACE. 

tympanic  cavity,  being  covered  by  mucous  membrane,  and  escapes 
through  the  Glaserian  fissure,  a  slit  in  the  anterior  part  of  the  floor 
of  the  tympanum,  into  the  glenoid  cavity. 

The  stylo-mastoid  artery,  derived  from  the  posterior  auricular, 
enters  the  stylo-mastoid  foramen  to  supply  the  facial  nerve  and  also 
the  mucous  membrane  of  the  tympanum. 

The  Eustachian  tube  reaches  from  the  tympanum  to  the  phar- 
ynx; its  outer  one-third  is  bony;  its  inner  two-thirds,  cartilaginous. 
Where  these  join,  the  tube  is  narrowest :  the  isthmus.  The  tube  opens 
into  the  anterior  end  of  the  tympanum,  near  the  drum ;  its  inner  end 
opens  into  the  pharynx  above  the  soft  palate  and  just  behind  the 
posterior  border  of  the  inferior  turbinated  bone.  The  walls  of  the 
cartilaginous  portion  of  the  tube  are  usually  in  contact  and  the  tube 
is  thus  closed.  To  ventilate  the  tympanum,  muscular  action,  which 
will  open  the  pharyngeal  end  of  the  tube,  is  required.  This  is  ac- 
complished by  the  muscles  of  the  soft  palate:  the  tensor  and  the 
levator  palati. 

OPERATIONS  UPON  THE  MASTOID,  ETC. 

Paracentesis  of  the  Drum  Membrane. — Incision  of  the  drum  mem- 
brane for  the  purpose  of  evacuating  pus  from  the  middle  ear.  If  this 
operation  is  done  early  enough  it  will  prevent  most  cases  of  acute 
middle-ear  disease  from  going  on  to  involvement  of  the  mastoid  antrum, 
etc.  By  means  of  direct  or  reflected  light  the  drum  is  brought  into 
view  and  incised.  The  incision  is  made  with  the  narrow-bladed  knife 
in  the  lower  posterior  quadrant  of  the  drum  and  should  be  sufficiently 
large  to  permit  of  free  drainage.  The  incision  in  this  part  of  the  drum 
is  least  likely  to  damage  important  structures. 

Wilde's  Incision.— This  consists  of  a  simple  incision  through  the 
soft  parts,  including  the  periosteum,  down  to  the  bone.  It  is  placed 
1  cm.  behind  and  parallel  with  the  auricle,  and  reaches  from  the 
base  of  the  mastoid  process  to  its  apex.  Usually  no  vessels  are  cut 
and  it  is  not  necessary  to  apply  any  ligatures.  It  is  often  sufficient 
in  very  young  children. 

To  Open  into  and  Drain  the  Antrum. — This  operation  is  indicated 
in  cases  of  acute  mastoid  disease.  The  patient  is  placed  with  the 
head  upon  the  side  resting  upon  a  thin  sandbag. 

Eegardless  of  any  condition  that  may  complicate  mastoid  disease, 
the  first  step  should  always  consist  in  freely  opening  and  draining  the 
mastoid  antrum. 


OPERATIONS  UPON  THE  MASTOID,  ETC.  123 

An  incision  is  made  1  cm. — Ya  ii^ch — behind  the  attachment 
of  the  auricle,  through  the  soft  parts,  including  the  periosteum,  down 
to  the  surface  of  the  bone,  and  reaching  from  the  base  of  the  mastoid 
to  its  tip.  In  this  incision  we  do  not  meet  the  posterior  auricular 
artery;  this  vessel  lies  just  anterior  to  the  line  of  incision  and,  as  a 
rule,  no  vessels  that  require  ligation  are  divided.  With  the  peri- 
osteum elevator  the  soft  parts,  including  the  periosteum,  are  separated 
from  the  surface  of  the  bone,  exposing  a  considerable  area  of  the 
surface  of  the  mastoid  process.  The  soft  parts  are  retracted  with 
broad,  sharp  retractors,  the  ear  and  anterior  edge  of  the  incision 
being  drawn  well  forward,  and  search  made  for  the  spina  supra 
nieatum,  the  spine  of  Henle,  which  is  the  guide  to  the  location  of 
the  mastoid  antnmi.  The  antrum  is  situated  one-half  to  three-quarters 
of  an  inch  beneath  the  surface  of  the  bone,  and  its  position  corresponds 
to  the  little  triangular  depression  which  is  found  just  behind  the  pos- 
terior margin  of  the  external  auditory  meatus,  spine  of  Henle.  The 
surface  of  bone,  which  has  been  thus  laid  bare,  may  be  soft,  discolored, 
and  may  further  present  the  orifice  of  a  fistula,  or  it  may  be  firm 
and  apparently  healthy  or  thickened,  sclerosed,  and  ivory-like.  If  the 
first  condition  exists, — ^that  is,  if  the  bone  is  softened,  carious,  etc., — 
one  may  easily  gouge  it  away  with  a  strong,  sharp  scoop,  continuing 
thus  until  the  antrum  is  reached.  If  the  surface  of  bone  which 
is  exposed  is  not  softened,  carious,  it  will  be  necessary  to  make  an 
opening  through  the  cortex  and  substance  of  the  bone  down  into  the 
mastoid  antrum.  In  cutting  through  the  bone  into  the  antrum  we 
commence  by  using  a  broad  chisel  or  gouge, — they  vary  in  width 
from  2  to  8  mm., — chipping  the  bone  out  in  the  form  of  a  circle  at 
least  three-fourths  inch  in  diameter.  This  excavation  is  carried  deeper 
into  the  substance  of  the  bone,  in  a  direction  inward  and  slightly  for- 
ward and  downward.  Working  parallel  with,  and  close  to,  the  pos- 
terior wall  of  the  auditory  canal,  we  must  necessarily  enter  the 
antrum.  As  we  progress,  narrower  chisels  or  gouges  may  be  used 
and  the  opening  made  smaller  in  diameter.  We  continue  thus,  oc- 
casionally sounding  with  the  probe,  until  the  antrum  is  entered,  at 
a  depth  corresponding  to  the  depth  of  the  auditory  canal.  The  an- 
trum may  contain  only  a  few  drops  of  pus.  During  this  part  of  the 
operation  the  field  must  be  kept  clear  of  blood  and  chips  of  bone  with 
a  stream  of  salt-water  or  by  sponging.  A  funnel-shaped  excavation, 
extending  through  the  substance  of  the  mastoid,  is  thus  made,  the 
base  of  the  opening  corresponding  to  the  external  surface  of  the  bone 


124  HEAD  AND  FACE. 

and  its  narrow  end  to  the  antrum.  The  base,  or  external  orifice,  of 
this  canal  should  be  sufiicientl}''  large  to  allow  of  convenient  work  in 
its  deeper  part. 

After  the  antrum  has  been  opened  the  cortex  is  gouged  away 
down  as  far  as  the  tip — ^this  may  be  conveniently  done  with  the 
rongeur — in  order  to  exjDose  and  drain  these  most  dependent  cells. 
The  bone  is  then  explored  with  the  probe  and  search  made  for  sinuses, 
soft,  carious  bone,  etc.  All  diseased  bone  is  gouged  away  with  the 
curette.  Fistulge  may  lead  into  the  auditory  canal  or  into  the  cranial 
cavity.  They  should  be  explored,  laid  open,  and  scraped  with  the 
curette.  At  times  the  cells  may  be  followed  backward  as  far  as  the 
thin  shell  of  bone  that  covers  the  sigmoid  sinus,  or  inward  into  the 
jugular  process  of  the  occipital  bone,  or  forward  into  the  root  of  the 
zygoma. 

When  the  antrum  has  been  opened  a  bent  probe  may  be  intro- 
duced and  carried  forward  through  the  aditus  into  the  t}Tnpanum. 
This  should  be  done  in  a  gentle  manner  so  as  not  to  injure  the  ossicles. 
The  drum  is  usually  already  perforated  and  fluid,  peroxid,  introduced 
into  the  antrum  with  the  syringe  will  escape  in  part  through  the  ear 
if  the  opening  from  the  antrum  into  the  tympanic  cavity  is  not  blocked 
by  swelling  of  the  mucous  membrane,  etc.  After  irrigating,  a  thin 
strip  of  iodoform  gauze  is  packed  into  the  excavation  in  the  mastoid, 
reaching  into  the  antrum,  and  the  edges  of  the  soft  parts  drawn  to- 
gether in  part  with  several  interrupted  sutures. 

In  order  to  avoid  accidental  opening  into  the  sigmoid  sinus, 
the  base,  the  commencement,  of  the  cone-shaped  canal  which  is 
chiseled  through  the  bone  into  the  antrum,  is  placed  anterior  to  the 
location  of  the  sinus;  and  as  we  proceed  deeper  into  the  substance 
of  the  bone  we  work  in  a  direction  forward,  downward,  and  inward, 
so  that  there  is  no  danger  of  injuring  the  sinus,  as  it  lies  behind  the 
most  posterior  part,  base,  of  this  excavation  in  the  bone,  and  as  we 
proceed  deeper  into  the  substance  of  the  bone  we  get  farther  away 
from  the  sinus.  It  is  of  but  little  consequence  if  the  sinus  is  ex- 
posed, but  one  should  avoid  accidentally  perforating  the  dura  and 
wounding  it.  If  the  sinus  is  opened,  the  hemorrhage  which  results 
may  be  controlled  by  packing  strip  gauze  into  the  wound,  between 
the  edge  of  the  bone  and  the  sinus.  Air  may  be  sucked  into  the 
sinus  if  it  is  opened,  but  this  is  not  accompanied  by  any  danger 
(Schwartz).  Accidental  opening  into  the  middle  fossa  of  the  skull 
is  avoided  by  commencing  the  channel  in  the  bone  beloAv  the  level 


OPERATIONS  UPON  THE  MASTOID,  ETC. 


135 


of  the  upper  margin  of  the  external  auditory  meatus,  below  the  spina 
supra  meatum,  aud,  as  we  proceed,  working  in  a  direction  rather 
downward.  The  floor  of  the  middle  fossa  will  thus  lie  above  the 
base  of  the  cone-shaped  canal  which  is  made  in  the  bone.  Simple 
exposure  of  the  dura  is  not  of  any  serious  consequence. 

If  one  does  not  chisel  beyond  the  antrum,  there  is  but  little 
danger  of  the  injuring  the  external  semicircular  canal,  the  facial 
nerve  or  the  inner  wall  of  the  t^nnpanum    (labyrinth).     The  facial 


Fig.  72.— Simple  Mastoid  Operation.  As  indicated  in  the  iUustration,  the 
operation  has  been  extensively  carried  out.  Practically  the  entire  cancellous 
substance  of  the  mastoid  process  has  been  chiseled  or  gouged  away.  Behind, 
S,  the  location  of  the  sigmoid  sinus,  covered  with  a  thin  shell  of  bone,  is  seen. 
Above,  A,  the  antrum  has  been  laid  freely  open.  F  shows  the  course  of  the 
facial  nerve  which  has  been  purposely  uncovered  in  order  to  show  its  position 
in  relation  to  the  operation. 

nerve,  contained  within  the  Fallopian  tube,  lies  rather  deeper  than 
the  antrum  and  anterior  to  it,  in  the  inner  wall  of  the  tympanum. 
If  one  penetrates  to  a  depth  of  2  cm.  or  more,  there  is  then  danger 
of  getting  beyond  the  antrum,  into  the  tympanic  cavity,  and  injuring 
the  semicircular  canal,  the  facial  nerve,  or  the  labyrinth. 

In  gouging  away  the  cancellous  tissue  of  the  mastoid  process 
inward,  forward,  and  downward  toward  the  tip  (from  the  level  of  the 
antrum  to  the  tip),  there  is  danger  of  uncovering  the  facial  nerve 


136  HEAD  AND  FACE. 

(see  Fig.  73).  Care  should  be  exercised,  in  this  part  of  the  opera- 
tion,  to  avoid  injuring  it. 

For  Thrombosis  of  the  Sigmoid  Sinus. — The  sigmoid  sinus  is  en- 
countered about  one-half  to  three-fourths  inch  posterior  to  the  bony 
auditory  canal  (spina  supra  meatum). 

One  should  always,  as  a  preliminary  step,  open  into  the  antrum 
as  described  above  and  from  here  start  out  to  investigate  the  sinus, 
etc.  After  the  antrum  has  been  opened  an  incision  is  carried  back- 
ward parallel  with  the  superior  curved  line  of  the  occipital  bone, 
through  the  soft  parts,  for  a  distance  of  about  two  inches,  and  with 
the  chisel  or  rongeur  the  bone  is  removed  in  a  direction  backward 
until  the  region  of  the  sinus  is  reached  and  the  dura  exposed.  The 
opening  in  the  skull  is  sufficiently  enlarged  by  cutting  away  its  mar- 
gin with  the  rongeur  forceps,  so  that  the  sinus  is  freely  exposed  and 
an  opening  ma.de  in  the  skull  which  is  sufficiently  large  to  work 
through.  This  opening  in  the  skull  should  have  a  diameter  of  at 
least  one  inch.  Oftentimes  pus  and  granulation  tissue  are  met  with 
just  as  soon  as  the  dura  is  exposed, — extradural  abscess, — and  if  the 
sinus  is  not  diseased  it  will  not  be  necessary  to  proceed  farther,  it 
being  sufficient  to  curette  and  drain  the  parts  about  the  sinus  without 
opening  into  the  latter. 

If  the  sinus  is  thrombosed,  it  will  appear  firm  and  prominent, 
and  in  case  of  doubt  an  aseptic  aspirating  needle  may  be  introduced. 
If  pus  is  not  present  in  the  sinus  and  the  needle  withdraws  fluid 
blood  it  does  not  necessarily  prove  that  the  sinus  is  unaffected.  Ten- 
derness along  the  course  of  the  internal  jugular,  etc.,  is  an  indication 
for  opening  the  sinus.  If  in  doubt  it  is  always  wise  to  incise  the  sinus, 
as  this  is  not  accompanied  by  any  special  danger. 

If  it  is  decided  to  open  the  sinus  this  should  be  done  by  making 
an  incision  corresponding  to  its  long  diameter,  with  a  sharp,  narrow- 
bladed  knife.  If  a  clot  is  found,  this  should  be  curetted  away  first 
from  the  jugular  end  down  to  the  bulb, — if  necessary,  removing  more 
bone  with  the  rongeur, — ^until  there  is  a  free  flow  of  blood:  good, 
free  bleeding  tends  to  wash  out  any  remaining  portions  of  clot.  This 
bleeding  may  be  readily  controlled  by  packing  a  small  strip  of 
gauze  into  the  space  between  the  sinus  and  the  adjoining  bone.  This 
flow  of  blood  does  not  necessarily  prove  that  there  is  not  a  clot  in 
the  jugular  vein  beyond  the  bulb :  blood  may  flow  around  from  the 
inferior  petrosal  sinus.  This  procedure  is  repeated  in  the  other  di- 
rection— i.e.,  toward  the  torcular — until  hemorrhage  is  established; 


OPERATIONS  UPON  THE  MASTOID,  ETC.  127 

this  may  then  be  controlled  in  a  similar  manner.  It  may  be  well, 
after  the  hemorrhage  has  been  controlled,  to  remove  the  packing 
and  freely  irrigate  the  sinus  with  normal  salt  solution. 

Before  opening  the  sigmoid  sinus  the  internal  jugular  vein,  the 
facial  vein,  etc.,  may  be  exposed  in  the  neck  and  tied ;  or  the  internal 
jugular  in  its  entirety  and  including  all  its  branches  may  be  resected 
through  an  incision  made  along  the  anterior  border  of  the  sterno- 
mastoid  muscle  after  first  having  tied  the  vessel  below,  at  the  clavicle, 
and,  above,  near  the  bulb  (avoid  the  pneumogastric  nerve).  This  pro- 
cedure is  indicated  especially  if  tenderness  and  induration  are  present 
along  the  course  of  the  internal  jugular  vein — along  the  anterior  bor- 
der of  the  sterno-mastoid  muscle.  The  incision  and  the  method  of 
exposing  the  internal  jugular  vein  are  quite  similar  to  those  described 
for  ligation  of  the  common  carotid  artery.  If  the  internal  jugular 
vein  has  not  been  tied,  it  may  be  compressed  in  the  neck,  during  the 
operation,  to  prevent  the  passage  of  dislodged  clots. 

Besides  the  condition  described,  we  may  find  an  opening  lead- 
ing through  the  dura  mater  to  a  collection  of  pus  beneath  the  dura 
or  within  the  cerebellum;  these  purulent  collections  may  also  be 
present  without  thrombosis  of  the  sinus  or  without  a  fistulous  open- 
ing in  the  dura.  All  fistulous  openings  should  be  thoroughly  explored 
and  treated  as  the  condition  indicates. 

For  Cerebellar  Abscess. — The  opening  in  the  skull  may  be  made 
with  a  trephine  or  chisel.  Usually  the  antrum  and  sinus  have  al- 
ready been  explored,  and  the  opening  in  this  case  may  be  simply 
extended  backward  with  the  rongeur.  The  center  of  the  opening 
in  the  skull  for  cerebellar  abscess  should  be  located  two  inches  behind 
the  external  auditory  meatus  and  should  be  placed  below  a  line  drawn 
from  the  upper  margin  of  the  external  auditory  meatus  to  the  external 
occipital  protuberance  (see  Pig.  69).  The  opening  in  the  bone  is 
thus  placed  below  the  superior  curved  line  of  the  occipital  bone,  and 
we  enter  therefore  below  the  attachment  of  the  tentorium  cerebelli 
and  below  the  course  of  the  lateral  sinus.  The  bone  is  here  very 
thin,  and  the  opening  may  be  readily  enlarged  to  any  necessary  extent 
with  the  rongeur.  A  good  free  opening  should  be  made  in  the  skull. 
Pus  may  be  found  between  the  dura  mater  and  the  bone,  extradural 
abscess,  and  one  may  discontinue  the  operation  at  this  stage,  pack 
and  await  the  result ;  or  there  may  be  a  fistulous  opening  in  the  dura 
leading  to  a  deeper,  purulent  collection.  In  this  case  the  fistulous 
opening  in  the  dura  is  enlarged  and  the  operation  continued.    If  there 


138  HEAD  AND  FACE. 

is  no  fistulous  opening  in  the  dura,  the  dura  is  incised  around  and 
fairly  close  to  the  margins  of  the  opening  in  the  skull,  and  the  flap 
of  dura  then  reflected,  thus  exposing  the  surface  of  the  brain.  The 
brain  shows  signs  of  tension,  absence  of  pulsation,  and  a  tendency 
to  bulge.  Strip  gauze  is  packed  into  the  subdural  space,  between  the 
dura  mater  and  pia-arachnoid.  The  abscess  may  be  quite  superficial, 
its  location  quite  obvious,  and  may  be  incised  at  once.  The  abscess 
may  be  deep-seated,  and  it  may  be  necessary  to  search  for  it  with 
the  aspirating  needle.  A  fairly  large  needle,  with  a  calibre  2  mm. 
in  diameter,  is  used.  If  the  pus  is  thin  it  will  escape  through  the 
needle  Avithout  using  the  syringe.  If  pus  does  not  appear  through 
the  needle  the  syringe  is  applied  and  suction  made,  at  the  same 
time  slowly  withdrawing  the  needle.  The  pus  may  be  so  thick  that 
it  cannot  be  withdrawn  by  aspiration,  and  it  may  be  necessary  to 
make  an  incision  into  the  suspected  area  with  the  knife  before  the 
pus  is  discovered.  If  the  pus  is  located  with  the  needle,  then,  without 
withdrawing  the  needle,  a  thin-bladed  artery  forceps  is  introduced 
down  alongside  the  needle  into  the  abscess  cavity  and  the  opening 
then  sufiiciently  enlarged  by  spreading  the  forceps  so  as  to  obtain 
an  opening  sufiiciently  large  to  admit  the  little  finger.  It  is  not  ad- 
visable to  irrigate  the  abscess  cavity,  nor  should  its  wall  be  curetted. 
The  cavity  is  loosely  packed  with  strip  gauze.  The  opening  in  the 
dura  is  closed  except  where  the  drain  emerges. 

For  Extradural  Abscess  in  the  Middle  Fossa. — There  may  be  an 
abscess  located  between  the  dura  mater  and  the  bone. 

If  the  mastoid  antrum  has  already  been  explored  a  fistula  may 
be  found  leading  through  the  roof  of  the  antrum  or  tympanum  into 
the  middle  fossa.  The  incision,  which  has  already  been  made  and 
through  which  the  mastoid  antrum  has  been  opened,  is  prolonged 
from  the  base  of  the  mastoid  in  a  direction  upward  and  forward 
over  the  ear,  dividing  the  temporal  vessels  and  the  temporal  muscle. 
With  the  rongeur  bone-forceps  or  chisel,  the  bone  is  cut  away  so  that 
the  middle  fossa  may  be  entered  just  above  and  in  front  of  the  external 
auditory  meatus;  here  we  work  in  between  the  tegmen  tympani  and 
the  dura  mater,  where  the  abscess  is  usually  located.  The  pus  is 
evacuated  and  the  abscess  cavity  packed  with  strip  gauze  and 
drained. 

For  Temporo-sphenoidal  Abscess. — Associated  with  the  extradural 
abscess  we  may  find  an  abscess  in  the  temporo-sphenoidal  lobe,  and 
there  may  be  a  fistula  leading  through  the  dura  and  communicating 


SURGICAL  ANATOMY  OF  THE  FACE.  129 

with  such  a  collection.  In  this  case  the  fistula  should  be  followed, 
enlarging  the  opening  in  the  dura,  evacuating  and  draining  the  abscess, 

A  temporo-sphenoidal  abscess  may  be  present  without  an  extra- 
dural abscess.  If  the  mastoid- antrum  has  already  been  explored,  etc., 
the  incision  that  has  already  been  made  for  that  purpose  may  be  ex- 
tended upward  and  forward  over  the  ear,  as  described  in  the  preceding 
operation,  and  sufficient  bone  gouged  out  with  the  rongeur,  proceeding 
from  the  opening  mastoid,  to  expose  the  temporo-sphenoidal  lobe 
of  the  brain. 

Independently  of  the  mastoid  operation  a  button  of  bone  may 
be  removed  with  the  trephine  from  the  side  of  the  skull  and  the 
opening  enlarged  wdth  the  rongeur.  The  center  of  the  opening  thus 
made  should  be  one  and  one-fourth  inches  above  and  one  inch  behind 
the  external  auditory  meatus  (see  Fig.  69).  The  portion  of  bone 
removed  corresponds  to  the  area  indicated  by  K"  L  N  M,  Fig.  43. 
The  temporo-sphenoidal  lobe  may  also  be  exposed  by  turning  down 
an  osteo-tegumentary  flap  in  the  temporal  region  (see  "Ligation  of 
the  Middle  Meningeal  Artery"). 

After  the  dura  has  been  exposed  and  incised  and  the  subdural 
space  packed  with  a  strip  of  gauze,  we  are  ready  to  open  the  abscess 
if  it  is  superficial,  or  search  for  it,  etc.,  if  it  is  deep,  as  described  in 
the  operation  for  "Cerebellar  Abscess." 

If  the  osteo-tegumentary  flap  method  of  exposure  has  been  used 
it  will  be  necessary  to  gouge  away  a  corner  of  the  bone  segment  to 
permit  the  exit  of  the  drain. 

THE  FACE. 

Surgical  Anatomy  of  the  Face. — The  skin  of  the  face  is  soft, 
thin,  and  intimately  united  to  the  underlying  muscles  and  connective 
tissue,  and  cannot  be  pinched  up  without  including  these  deeper  layers. 
The  subcutaneous  tissue  of  the  face  is  widely  meshed,  and  within 
these  meshes  there  is  contained  much  fat.  Those  parts  of  the  face 
where  the  fat  is  absent  from  the  subcutaneous  layer  are  loose  and 
flaccid, — for  example,  under  the  eyes, — and  become  marked  early  in 
life  by  wrinkles.  These  parts  also  readily  become  swollen  and  dis- 
tended in  dropsical  conditions.  In  this  layer  are  contained  the  mus- 
cles of  expression  and  the  vessels  and  nerves. 

The  facial  artery  is  the  chief  source  of  supply  to  the  face.  It 
is  a  large  vessel  derived  from  the  external  carotid.  It  pursues  a 
tortuous   course,  upward   and   forward,   across  the   side  of  the  face, 


130  HEAD  AND  FACE. 

from  the  anterior  border  of  the  masseter  to  the  angle  of  the  mouth, 
and  then,  as  the  angular,  continues  upward  alongside  the  nose,  anas- 
tomosing at  the  inner  canthus  with  a  branch  of  the  ophthalmic. 
Just  below  the  corner  of  the  mouth  the  facial  gives  off  a  branch,  the 
inferior  labial,  for  the  supply  of  the  lower  lip;  those  from  either 
side  anastomose.  At  the  corner  of  the  mouth  the  facial  gives  off 
the  inferior  and  superior  coronary.  These  branches  pass  inward, 
lying  a  little  beyond  the  edge  of  either  lip  and  situated  beneath 
the  mucous  membrane :  between  it  and  the  muscular  structure  of 
the  lip.    Those  from  either  side  anastomose  freely  with  their  fellows. 

The  facial  vein,  which  accompanies  the  artery,  is  not  tortuous, 
and  lies  superficial  to  the  artery. 

The  facial  nerve  supplies  the  muscles  of  expression,  etc.,  and 
the  buccinator.  It  emerges  from  the  parotid  gland  upon  the  side 
of  the  face  at  a  point  corresponding  to  the  lower  border  of  the  lobe 
of  the  ear,  and  divides  into  branches  which  supply  the  facial  mus- 
cles and  the  platysma  (see  page  138).  The  sensory  supply  to  the  face 
and  teeth  is  derived  from  the  fifth  nerve. 

The  Seeleton"  of  the  Face. — The  upper  part  consists  of  the 
superior  maxillary  and  the  adjoining  bones  with  which  it  articulates 
and  which  serve  to  join  it  to  the  skull;  it  articulates,  toward  the 
middle  line,  with  the  nasal  bones  which  form  the  bridge  of  the  nose 
and  laterally  with  the  malar.  The  malar  bone  forms  the  prominent 
part  of  the  cheek  and  gives  off  a  process  which  passes  backward  and 
unites  with  a  similar  process  from  the  temporal  to  form  the  zygo- 
matic arch. 

The  body  of  the  superior  maxillary  is  pyramidal,  its  base  being 
directed  inward  toward  the  nasal  cavity,  forming  part  of  its  outer 
wall  and  presenting  the  opening  into  the  antrum  of  Highmore;  its 
apex  corresponds  to  its  junction  with  the  malar.  The  upper  surface 
of  the  superior  maxillary  is  thin  and  forms  the  floor  of  the  orbit.  Its 
anterior  or  facial  surface  is  very  thin  in  places  and  easily  perforated; 
it  is  rather  concave,  and  just  below  the  margin  of  the  orbit  presents 
the  opening  of  the  infra-orbital  canal.  A  line  drawn  from  the  supra- 
orbital notch  straight  downward  to  a  point  between  the  two  lower 
bicuspid  teeth,  called  Holden's  line,  crosses  the  infra-orbital  fora- 
men one-quarter  inch  below  the  inferior  margin  of  the  orbit  and  the 
mental  foramen  midway  between  the  upper  and  lower  borders  of  the 
inferior  maxilla.  These  foramina  give  exit  to  the  corresponding 
branches  of  the  fifth  nerve,  which  it  may  be  desirable  to  reach  in 


SURGICAL  ANATOMY  OF  THE  FACE.  131 

severe  neuralgia.  A  canal  descends,  as  an  offshoot  from  the  infra- 
orbital canal,  through  the  anterior  wall  of  the  bone;  it  transmits  a 
nerve-branch  which  supplies  the  upper  front  teeth.  The  posterior, 
or  zygomatic,  surface  of  the  superior  maxilla  looks  backward  and 
outward  toward  the  zygomatic  fossa;  it  gives  origin,  in  part,  to  the 
external  pterygoid  muscle,  and  is  in  close  relation  with  the  termina- 
tion of  the  internal  maxillary  artery.  This  surface  presents  the 
commencement  of  the  superior  dental  canal  for  the  transmission  of 
the  superior  dental  nerve  to  the  upper  back  teeth. 

The  body  of  the  bone  is  hollowed  out.  The  space  within,  Imown 
as  the  antrum  of  Highmore,  communicates  with  the  nasal  cavity 
through  an  opening  into  the  middle  meatus,  and  is  lined  with  mu- 
cous membrane,  which  is  continuous  with  that  of  the  nose.  The 
walls  inclosing  the  antrum  are  thin,  but  strengthened  by  columns  of 
bone  which  ascend  from  the  tooth  sockets  and  converge  toward  the 
apex,  malar  process;  in  this  way  the  bone  is  strengthened  and  the 
shock  of  blows  distributed.  The  alveolar  process  is  solid  and  presents 
the  sockets  for  the  teeth.  The  palate  process,  projecting  inward, 
joins  with  its  fellow  of  the  opposite  side,  and  together  with  the  hori- 
zontal plates  of  the  palate  bones  forms  the  hard  palate :  the  floor 
of  the  nasal,  and  the  roof  of  the  buccal,  cavity. 

The  periosteum  covering  the  upper  jaw  is  thin  and  closely  at- 
tached to  the  surface  of  the  bone.  It  is  rather  more  easily  separated 
from  the  orbital  and  facial  surfaces. 

The  lower  part  of  the  face  is  composed  of  the  inferior  maxillary, 
which  consists  of  a  body  and  two  rami  and  which  is  attached  to  the 
skull  through  the  temporo-maxillary  articulations.  The  body  of  the 
bone  is  horseshoe-shaped,  presenting  an  upper  border,  with  sockets 
for  the  teeth,  and  a  lower  rounded  border,  which  may  be  felt  beneath 
the  integanneut. 

To  the  inner  surface  of  the  body  of  the  inferior  maxillary  are 
attached  the  muscles  which  form  the  floor  of  the  mouth,  and  in 
front,  at  the  symphysis,  are  attached  the  muscles  which  draw  the 
tong-ue  foi'^\'ard  and  prevent  its  dropping  back  into  the  pharjTix. 

The  ramus  is  a  perpendicular  plate  of  bone  with  an  upper  curved 
border  which  presents,  in  front,  a  thin,  pointed  process,  the  coracoid, 
to  which  is  attached  the  tendon  of  the  temporal  muscle,  and,  behind, 
a  rather  thickened  process,  the  condyle.  The  upper  surface  of  the 
condyle  is  rounded  and  smooth,  for  articulation  with  the  glenoid 
cavit}'.      Below   the   articular   surface   there   is   a  rather   constricted 


132  HEAD  AND  FACE. 

portion,  known  as  the  neck.  To  the  front  surface  of  the  neck  of  the 
condyle  is  attached  the  tendon  of  the  external  pter3'goid  muscle.  The 
lower  posterior  corner  of  the  ramus  is  a  prominent  landmark,  and  is 
called  the  angle  of  the  jaw.  The  outer  surface  of  the  ramus  is  cov- 
ered by  the  masseter  and  gives  attachment  to  this  muscle.  The  inner 
surface  of  the  ramus  presents,  about  its  middle,  the  orifice  of  the 
inferior  dental  canal,  into  which  the  nerve  of  the  same  name  passes 
to  supply  the  teeth  of  the  lower  jaw.  The  anterior  margin  of  this 
orifice  is  marked  by  a  small  pointed  process  of  bone,  to  which  the 
long  internal  lateral  ligament  is  attached.  The  internal  pterygoid 
muscle  is  attached  to  the  lower  posterior  part  of  the  inner  surface  of 
the  ramus. 

Sixteen  teeth  are  inserted  in  each  jaw,  eight  on  a  side:  two 
incisors  nearest  the  middle  line,  and,  following  these,  one  canine, 
two  bicuspids,  and  three  molars. 

The  Mouth. — The  mouth  is  inclosed  by  the  lips  and  cheeks. 

The  lips  are  composed  of  fatty  connective  tissue  and  muscular 
tissue,  and  are  covered  externally  by  the  skin  and  internally  by 
the  mucous  membrane.  The  muscular  fibers  are  found  in  the  sub- 
cutaneous connective-tissue  layer,  coming  from  iall  directions  and 
interlacing  with  each  other,  and  with  much  fatty  tissue  interspersed 
between  them.  The  mucous  membrane,  lining  the  inner  surface  of 
the  lips,  is  continued  over  upon  the  gums.  In  the  middle  line,  from 
the  lip  to  the  gum,  there  is  a  thin,  delicate  fold  of  mucous  mem- 
brane, the  frsenum,  which  is  well  seen  when  the  lip  is  drawn  away 
from  the  gum.  The  vessels  to  the  lips  are  the  labial  and  the  inferior 
coronary  to  the  lower  lip,  and  the  superior  coronary  to  the  upper 
lip.     These  branches  are  derived  from  the  facial. 

The  cheeks  are  formed  of  skin,  connective  tissue  and  fat,  buc- 
cinator muscle,  and  mucous  membrane.  The  buccinator  muscle  is 
attached  to  the  outer  surface  of  the  upper  and  lower  jaw-bones  just 
beyond  the  alveolar  processes.  This  muscle  is  covered,  upon  its 
external  surface,  by  a  layer  of  fascia,  bucco-pharjmgeal,  which  is  con- 
tinuous behind  with  that  covering  the  constrictors  of  the  pharynx. 
The  mucous  membrane  lining  the  inner  surface  of  the  cheeks  is 
continuous  with  that  of  the  gums.  The  buccal  cavity  may  be  divided 
into  an  outer  space,  the  vestibule,  and  an  inner  space,  the  mouth 
proper.  The  vestibule  is  the  space  between  the  teeth  and  the  cheeks 
and  lips.  When  the  mouth  is  closed  the  mucous  membrane  lining 
the  cheeks  is  thrown  into  the  folds,  which  would  be  caught  between 


MOUTH.  133 

the  teeth  if  not  prevented  by  the  contraction  of  the  buccinator  to 
which  the  mucous  membrane  is  firmly  attached. 

Opposite  the  second  upper  molar  tooth  is  the  orifice  of  Stenson's 
duct.  At  times  this  orifice  is  marked  by  a  papilla,  which  may  assist 
in  locating  it. 

The  mucous  membrane,  from  the  lips  and  cheeks,  is  reflected 
upon  the  alveolar  process  of  the  upper  and  lower  jaw  and  extends 
between  the  teeth.  It  is  intimately  united  with  the  periosteum  cov- 
ering the  bone,  and  together  with  it  forms  the  gums.  Behind  the 
last  molar  tooth  the  anterior  border  of  the  ramus  of  the  jaw  may 
be  felt,  and  upon  the  outer  side  of  this  the  masseter  muscle  may 
also,  when  contracted,  be  distinctly  recognized.  When  the  teeth  are 
tightly  closed,  the  vestibule  communicates  with  the  cavity  of  the 
mouth  proper  by  a  small  space  behind  the  last  molar  tooth  upon 
either  side. 

The  cavity  of  the  mouth  proper  presents  a  roof  and  a  floor,  and 
is  bounded  in  front  and  upon  the  sides  by  the  alveolar  processes  and 
the  teeth.  Behind,  the  mouth  opens  into  the  pharynx.  It  is  sepa- 
rated from  the  lar}Tix  by  the  epiglottis,  and  from  the  posterior 
nasal  space  by  the  soft  palate.  Where  the  cavity  of  the  mouth  opens 
into  the  pharynx  it  is  somewhat  narrowed  and  is  called  the  isthmus 
of  the  fauces.  The  isthmus  is  bounded  above  by  the  free  edge  of  the 
soft  palate;  below,  by  the  tongnie;  and,  upon  the  sides,  by  the  pillars 
of  the  fauces. 

The  roof  of  the  mouth  is  divided  into  the  hard  and  soft  palate. 
The  hard  palate  is  formed  by  the  junction,  in  the  middle  line,  of 
the  palatal  processes  of  the  superior  maxillaries  in  front,  and  of  the 
horizontal  plates  of  the  palate  bones,  behind.  It  is  concave,  and 
arched  from  side  to  side  and  from  before  backward.  In  front,  in 
the  middle  line,  just  behind  the  incisor  teeth,  is  a  foramen,  the 
orifice  of  the  anterior  palatine  canal,  which  transmits  the  anterior 
palatine  vessels.  Extending  from  this  foramen,  forward  and  out- 
ward, to  a  point  between  the  lateral  incisors  and  the  canine  teeth, 
on  either  side,  may  be  seen,  occasionally,  a  line  which  marks  the 
junction  of  the  intermaxillary  bone  with  the  palatal  processes  of 
the  superior  maxillaries. 

Near  the  posterior  edge  of  the  hard  palate,  just  to  the  inner 
side  of  the  last  molar  tooth,  is  the  orifice  of  the  posterior  palatine 
canal,  and  passing  forward  from  this  is  a  groove,  close  to  the  alveolar 
process.     The  posterior  palatine  vessels  descend  through  the  poste- 


134  HEAD  AND  FACE. 

rior  j^alatine  canal  and  then  pass  forward^  npon  tlie  hard  palate, 
Ijdng  in  the  groove  just  mentioned.  Behind  the  orifice  of  the  poste- 
rior palatine  canal  may  be  seen  the  hook-like  hamnlar  process :  the 
termination  of  the  internal  pterygoid  process,  around  which  the  ten- 
don of  the  tensor  palati  is  reflected  before  it  spreads  out  in  the  soft 
palate.  The  mucous  membrane  and  periosteum,  which  cover  the 
hard  palate,  are  intimately  united  with  each  other  and  to  the  surface 
of  the  bone. 

The  soft  palate  is  a  curtain-like  structure  suspended  from  the 
posterior  border  of  the  hard  palate.  It  is  composed  of  the  spread- 
out  aponeuroses  of  the  tensor  and  levator  palati.  It  marks  the 
boundary  line  between  the  mouth  and  the  pharjrnx.  It  presents  an 
inferior,  or  anterior,  and  a  superior,  or  posterior,  surface,  each  cov- 
ered with  mucous  membrane. 

The  lower,  or  free,  border  of  the  soft  palate  presents,  in  the 
middle  line,  the  uvula  and  upon  either  side  separates  into  the  ante- 
rior and  posterior  pillars  of  the  fauces.  The  anterior  pillar  is  con- 
tinued downward  into  the  side  of  the  base  of  the  tongTie  at  a  point 
just  behind  the  last  molar  tooth  of  the  lower  jaw,  and  is  made  up 
of  the  palato-glossus  muscle.  The  posterior  pillar  is  continued 
downward  and  backward  into  the  side  of  the  pharjmx,  and  is  com- 
posed of  the  palato-pharyngeus  muscle.  Between  the  two  pillars  of 
the  fauces  there  is  a  triangular  space  which  lodges  the  tonsil.  Just 
above  the  soft  palate,  in  the  side  of  the  pharjTix,  is  the  orifice  of  the 
Eustachian  tube ;  it  is  about  on  a  level  with  the  floor  of  the  nose. 

In  quiet  breathing  the  soft  palate  hangs  passive;  but  during 
the  act  of  swallowing  it  becomes  tense,  owing  to  the  contraction  of 
its  muscles,  and  its  free  border  then  comes  into  contact  with  the 
posterior  wall  of  the  pharynx,  thus  shutting  off  the  posterior  nasal 
space  from  the  cavity  of  the  mouth. 

The  floor  of  the  mouth  is  formed  of  soft  parts :  chiefly  by  the 
mylo-hyoid  muscle.  This  muscle  extends  from  the  mylo-hyoid  ridge, 
upon  the  inner  surface  of  the  body  of  the  inferior  maxilla,  to  the 
body  and  greater  comu  of  the  hyoid  bone,  uniting  with  its  fellow 
in  the  middle  line.  The  upper  surface  of  the  muscle,  which  is  di- 
rected toward  the  cavity  of  the  mouth,  is  covered  over  by  the  mucous 
membrane,  beneath  which  are  found,  on  either  side,  the  sublingual 
gland,  Wharton's  duct,  the  gustatory  nerve,  etc.  The  external  sur- 
face of  the  mylo-hyoid  muscle  forms  part  of  the  floor  of  the  sub- 
maxillary triangle,  and  is  in  relation  with  the  submaxillary  gland. 


MOUTH.  135 

The  Tongue  is  a  muscular  organ  which  projects  upward  and 
forward  from  the  floor  of  the  mouth.  It  is  attached  by  its  base 
and  through  several  muscles  to  the  hj^oid  bone,  and  is  connected 
with  the  epiglottis  through  the  giosso-epiglottidean  folds  of  mucous 
membrane.  The  tongue  is  composed  of  a  mass  of  muscular  and 
connective  tissue  interspersed  with  much  fat,  and  is  partly  divided 
into  two  symmetrical  halves  by  a  fibrous  septum.  The  tongue  is 
connected  with  the  hyoid  bone  by  the  hyo-glossus  muscle  on  each 
side;  with  the  styloid  process  by  the  stylo-glossus ;  with  the  soft 
palate  by  the  palato-glossus,  and  through  the  genio-hyo-glossus  with 
the  symphysis  of  the  lower  jaw-bone — this  muscle  serves  to  draw 
the  tongue  forward  and  prevents  its  dropping  back  into  the  pharynx 
and  obstructing  breathing, 

When  the  mouth  is  closed  its  cavity  is  almost  completely  occu- 
pied by  the  tongue.  The  anterior  part  of  the  upper  surface  of  the 
tongue  is  in  contact  with  the  hard  palate;  the  posterior  part,  with 
the  soft  palate  and  the  epiglottis.  The  tongue  is  covered  by  mucous 
membrane,  that  covering  the  under  surface  and  sides  of  the  organ 
being  similar  to  that  of  the  rest  of  the  mouth.  That  covering  its 
upper  surface,  dorsum,  is  rough,  marked  by  numerous  glands,  and 
composed  of  a  thick  layer  of  flat  epithelium,  which  gives  it  rather 
a  grayish  color.  The  dorsum  of  the  tongue  is  convex  and  presents 
in  the  middle  line  a  raphe,  which  divides  the  organ  into  two  sym- 
metrical halves.  Behind,  near  the  base,  the  tongue  presents  a  row 
of  large  papillae,  circumvallate  papillae,  arranged  in  a  row,  V-shaped, 
with  the  apex  backward.  In  the  middle,  corresponding  to  the  apex 
of  the  two  rows  of  papillae,  is  a  deep  depression,  the  foramen  ccecum. 
This  is  the  remains  of  the  foetal  thyro-glossal  duct,  from  which 
cystic  tumors  and  dermoid  cysts  may  develop. 

The  tongue  may  be  split  or  fissured  at  the  tip  owing  to  lack  of 
fusion,  indicating  the  two  halves  of  which  it  is  formed.  If  the 
tongue  is  lifted  away  from  the  floor  of  the  mouth  by  its  tip,  the 
attachment  of  its  under  surface  to  the  floor  of  the  mouth,  in  the 
middle  line,  through  a  membranous  band,  the  fraenum  linguae,  is 
seen.  The  fraenum  may  be  so  short  as  to  limit  the  mobility  of  the 
tongue — "tongue-tie" — to  such  an  extent  that  it  seriously  interferes 
with  speech,  and  requires  cutting. 

The  sublingual  glands  consist  each  of  a  number  of  lobules,  and 
are  located  in  the  front  part  of  the  mouth,  upon  either  side  of  the 
fraenum,  resting  upon  the  mylo-hyoid  muscle  and  covered  over  by 


136  HEAD  AND  FACE. 

the  mucous  membrane.  The  location  of  the  glands  is  indicated  by 
a  slight  swelling  in  the  floor  of  the  mouth,  which  presents  the  little 
pin-point  orifices  of  their  excretory  ducts. 

Upon  either  side  of  the  frsenum  there  is  a  little  papilla  showing 
the  orifice  of  Wharton^s  duct.  This  is  the  excretory  duct  of  the 
submaxillary  gland.  It  passes  forward,  through  the  floor  of  the 
mouth,  lying  below  and  to  the  inner  side  of  the  sublingual  gland. 
The  duct  may  become  blocked  by  a  calculus  and  become  greatly  dis- 
tended, appearing  in  the  floor  of  the  mouth  as  a  cystic  swelling — 
called  a  ranula. 

Each  half  of  the  tongue  is  supplied  by  the  corresponding  lingual 
artery;  this  is  a  large  branch  which  is  given  off  from  the  external 
carotid  just  above  the  greater  comu  of  the  hyoid  bone.  It  passes  for- 
ward beneath  the  hyo-glossus  muscle,  and  ascends  beneath  this  mus- 
cle to  the  under  surface  of  the  tongue,  where  it  is  continued  forward 
to  its  tip.  The  chief  vein  of  the  tongue  is  the  ranine,  a  large  branch, 
which  passes  backward  upon  the  outer  surface  of  the  hyo-glossus 
muscle  and  terminates  in  the  internal  jugular. 

The  nerves  to  the  tongue  are  the  hypoglossal,  the  gustatory, 
and  the  glosso-pharyngeal.  The  hypoglossal  descends  in  the  neck 
as  far  as  the  point  where  the  occipital  artery  is  given  off  from  the 
external  carotid;  here  it  passes  forward,  above  and  parallel  with 
the  greater  cornu  of  the  hyoid  bone,  resting  upon  the  hyo-glossus 
muscle.  The  gustatory  is  one  of  the  branches  derived  from  the  third 
division  of  the  fifth  nerve.  From  its  origin  it  descends  in  front  of 
the  inferior  maxillary  nerve,  lying  between  the  internal  pterygoid 
muscle  and  the  ramus  of  the  jaw;  here  it  communicates  with  the 
chorda  tympani,  from  the  facial,  and  passing  forward,  beneath  the 
body  of  the  jaw  and  above  the  submaxillary  gland,  gives  off  its 
branches  to  the  submaxillary  ganglion;  continued  forward,  upon  the 
hyo-glossus  muscle,  it  crosses  Wharton's  duct,  and  is  continued  along- 
side the  tongue  to  its  apex,  lying  directly  beneath  the  mucous  mem- 
brane. The  glosso-pharyngeal  is  of  but  little  surgical  importance. 
It  descends  in  the  neck,  in  front  of  the  internal  jugular  vein  and 
the  internal  carotid  artery,  curving  forward  upon  the  outer  side 
of  the  stylo-pharyngeus  muscle,  to  be  distributed  to  the  base  of  the 
tongue,  etc. 

The  Side  of  the  Face. — Passing  transversely  from  behind  for- 
ward beneath  the  integument,  the  zygomatic  arch  may  be  felt.  This 
bony  arch  is  formed  by  the  junction  of  the  zygomatic  process  of  the 


SIDE  OF  THE  FACE.  137 

temporal  with  that  of  the  malar.  It  is  a  prominent  landmark,  and 
serves  to  separate  the  side  of  the  head,  the  temporal  region,  from 
the  side  of  the  face,  the  pterygo-maxillary  region. 

The  Pterygo-maxillary  Eegion  corresponds  to  that  part  of 
the  side  of  the  face  which  is  situated  below  the  level  of  the  zygoma. 

The  skin  of  this  region  is  intimately  connected  with  the  under- 
lying subcutaneous  connective  tissue,  which  is  thick  and  only  loosely 
attached  to  the  fascia  covering  the  masseter  muscle. 

The  masseter  muscle  is  a  strong,  thick  muscle  arising  by  two 
portions  from  the  lower  border  and  inner  surface  of  the  zygoma.  Its 
fibers  pass  downward,  covering  the  ramus  of  the  jaw,  to  the  outer 
surface  of  which  and  to  the  angle  of  the  jaw  it  is  attached.  It  is 
covered  by  an  expansion  of  the  cervical  fascia,  which  is  attached 
above  to  the  lower  border  of  the  zygoma.  The  facial  artery  crosses 
the  lower  border  of  the  inferior  maxilla  just  in  front  of  the  masse- 
ter muscle,  grooving  the  bone  in  this  situation  and  passing  upward 
and  forward  across  the  cheek  to  the  side  of  the  nose.  It  is  accom- 
panied by  the  facial  vein,  which  joins  with  a  branch  from  the  tem- 
poro-maxillary  and  thus  constitutes  a  big  branch,  the  temporo-facial, 
which  terminates  in  the  internal  jugular. 

The  Parotid  GtLAnd. — After  the  skin  and  subcutaneous  fat 
have  been  removed  in  this  region  the  parotid  gland  is  exposed.  The 
parotid  gland  is  a  reddish,  glandular  mass,  situated  in  front  of  the 
ear,  and  packed  into  the  space  or  recess  between  the  ramus  of  the 
jaw  anteriorly  and  the  mastoid  process  and  anterior  edge  of  the 
sterno-mastoid  muscle  posteriorly,  and  the  styloid  process  internally. 
It  reaches  from  the  zygoma  above  to  the  angle  of  the  jaw  below, 
and  is  continued  forward  upon  the  side  of  the  face,  resting  upon 
the  masseter  muscle  for  a  variable  distance.  This  portion  is  called 
the  facial  process.  The  parotid  gland  is  enclosed  within  a  fibrous 
capsule  derived  from  the  cervical  fascia.  That  portion  which  covers 
the  gland  externally  is  attached,  above,  to  the  zygoma;  behind,  to 
the  anterior  border  of  the  sterno-mastoid  muscle;  below,  it  is  con- 
tinuous with  the  cervical  fascia,  and  anteriorly  it  is  continued  forward 
to  the  masseter,  and  becomes  fused  with  the  fascia  that  covers  that 
muscle'.  The  duct  of  Stenson  (duct  of  the  parotid  gland)  is  about 
two  inches  long  and  lies  about  a  finger's  breadth  below  the  zygoma, 
passing  forward  across  the  masseter,  at  the  anterior  border  of  which 
it  pierces  the  cheek  to  enter  the  mouth  opposite  the  second  molar 
tooth  of  the  upper  jaw.     Stenson's  duct  may  become  occluded  by 


138  HEAD  AND  FACE. 

a  calculus.  Introduction  of  a  probe  into  Stenson's  duct  is  facilitated 
by  everting  the  cheek. 

The  facial  nerve,  after  emerging  from  the  styloid  foramen,  passes 
forward  and  downward  into  the  substance  of  the  parotid  gland.  It 
crosses  (superficially)  the  external  carotid  artery  and  the  temporo- 
maxillary  vein,  and  divides,  in  the  substance  of  the  parotid  gland, 
into  its  two  terminal  branches,  temporo-facial  and  cervico-facial. 
These  terminal  branches  subdivide  further,  upon  the  side  of  the 
face  and  neck,  to  supply  the  muscles,  etc.,  of  the  face  and  neck.  The 
facial  nerve  can  be  rolled  under  the  finger  against  the  bone  as  it 
crosses  the  posterior  border  of  the  ramus  of  the  lower  jaw,  upon  a 
level  with  the  lower  border  of  the  lobe  of  the  ear. 

The  auriculo-temporal  nerve  emerges  upon  the  face  behind  the 
neck  of  the  condyle  of  the  jaw  after  passing  through  the  upper  part 
of  the  parotid  gland.  It  ascends  across  the  root  of  the  zygoma,  in 
front  of  the  ear,  in  company  with  the  temporal  artery,  to  be  dis- 
tributed upon  the  side  of  the  head  (temporal  region). 

Abscess  of  the  parotid  gland  is  not  uncommonly  met  with.  They 
may  be  due  to  direct  infection  carried  along  Stenson's  duct  from 
the  mouth,  or  they  ma)''  be  metastatic.  They  are  very  painful  and 
do  not  tend  to  come  to  the  surface  on  account  of  the  dense  fascia 
that  invests  the  gland.  They  may  burrow  deep  toward  the  pharynx 
or  into  the  deep  layers  of  the  neck,  or  they  may  discharge  through 
the  auditory  canal. 

In  making  incisions  into  the  parotid  gland  it  is  necessary  to 
avoid  Stenson's  duct  and  the  facial  nerve.  The  incisions  should  be 
made  with  the  knife  through  the  skin  and  fat  in  a  horizontal  line — 
parallel  with  the  zygoma.  The  fibrous  layer — capsule  of  the  gland — ■ 
should  be  penetrated  bluntly  with  the  artery  forceps.  The  opening 
which  is  thus  made  is  enlarged  to  a  sufficient  degree  by  spreading  the 
blades  of  the  forceps.  In  incising  deep  into  the  parotid  gland  the 
facial  ner\^e,  external  carotid  artery,  or  temporo-maxillary  vein  may 
be  divided. 

Beneath  the  parotid  gland  or  within  its  substance  the  external 
carotid  artery  divides  into  its  terminal  branches :  the  internal  maxil- 
lary and  the  temporal.  The  temporal  ascends  through  the  substance 
of  the  gland  and  across  the  root  of  the  zygoma,  just  in  front  of  the 
cartilage  of  the  ear,  the  auriculo-temporal  nerve  lying  posterior  to 
it;  and  about  two  inches  above  the  zygoma  it  divides  into  the  ante- 
rior and  posterior  temporal.     These  branches,  lodged  in  the  subcu- 


SIDE  OF  THE  FACE.  I39 

taneous  connective-tissue  layer  of  the  temporal  region,  divide  and 
supply  this  part  of  the  scalp,  anastomosing  anteriorly  with  branches 
from  the  frontal  and  posteriorly  with  the  occipital,  etc.  The  inter- 
nal maxillary  artery  is  not  exposed  until  after  the  removal  of  the 
ramus  of  the  jaw,  etc.  (see  later).  The  temporal  artery  is  accom- 
panied by  the  temporal  vein.  The  temporal  vein  does  not  lie  within 
the  substance  of  the  parotid  gland,  but  superficial  to  it;  it  receives 


Fig.  73. — Pterygo-raaxniary  Region.  Ramus  of  tlie  jaw  and  ttie  zygomatic 
arch  cut  away.  ID,  inferior  dental  nerve;  IM,  internal  maxillary  artery; 
L,  lingual,  or  gustatory,  nerve;  PE,  external  pterygoid  muscle;  PI,  internal 
pterygoid  muscle;  SM,  superior  maxillary  (second  division  of  fifth)  nerve 
crossing  the  spheno-maxillary  fossa  from  behind  forward. 

many  tributaries,  and  below  the  angle  of  the  jaw  divides  into  two 
branches ;  the  posterior  joins  with  the  posterior  auricular  to  form 
the  external  jugular  vein;  the  anterior  joins  with  the  facial  to  form 
a  large  branch,  the  temporo-facial,  which  passes  obliquely  backward 
across  the  upper  part  of  the  superior  carotid  triangle,  to  enter  the 


140  HEAD  AND  FACE. 

internal  jugular.  This  branch  is  often  cut  in  extirpating  glands^  etc., 
in  this  part  of  the  neck,  and  may  give  rise  to  profuse  hemorrhage. 

The  deeper  parts  of  this  region  are  exposed  by  dividing  the 
zygomatic  arch  with  the  chisel  or  the  G-igli  saw  at  its  anterior  and 
posterior  extremities,  and  then,  after  cutting  the  attachment  of  the 
temporal  fascia  from  its  upper  border,  turning  the  detached  segment 
of  the  arch,  with  the  attached  masseter,  downward.  There  is  then 
exposed  the  upper  part  of  the  ramus  of  the  jaw,  with  its  coracoid 
process,  to  which  the  tendon  of  the  temporal  is  attached.  This 
process  is  now  cut  away  from  the  ramus,  and,  together  with  the 
attached  tendon  of  the  temporal,  turned  upward,  and  we  then  have 
exposed  to  view  the  pterj^go-maxillary  region  proper.  Occupying  this 
space  is  the  external  pterygoid  muscle.  This  muscle  arises,  by  its 
broad  anterior  end,  from  the  under  surface  of  the  great  wing  of 
the  sphenoid  and  from  the  outer  surface  of  the  external  pterygoid 
plate;  behind,  its  narrow  end  is  attached  to  a  depression  in  the 
anterior  surface  of  the  neck  of  the  condyle  of  the  lower  jaw  and  to 
the  anterior  margin  of  the  interarticular  fibrocartilage  of  the  tem- 
poro-maxillary  joint.  Curving  around  its  lower  border  and  passing 
forward  and  upward  upon  its  outer  surface  may  be  seen  the  internal 
maxillary  artery.  This  vessel  gives  off  branches  to  the  adjoining 
muscles  and  disappears,  anteriorly,  by  passing  into  the  spheno- 
maxillar}^  fossa  between  the  two  heads  of  the  external  pterygoid 
muscle.  There  is  a  rich  venous  plexus,  the  pterygoid,  which  is  made 
up  of  numerous  inter  anastomosing  veins  which  form  a  net-work  upon 
both  sides  of  the  external  pterygoid  muscle.  This  plexus  is  formed 
of  branches  which  are  derived  from  the  nasal  and  orbital  cavities 
and  of  some  which  communicate  with  the  cavernous  sinus.  The 
plexus  terminates  in  the  internal  maxillary  vein.  The  plexus  may 
give  rise  to  free  venous  hemorrhage  in  operations  deep  in  this  region. 
The  internal  maxillary  artery  pass  through  the  network  of  veins 
of  the  pterygoid  plexus.  The  internal  maxillary  artery  may  now 
be  cut  away  and  the  external  pterygoid  muscle  cut  short  at  its  at- 
tachment to  the  condyle  of  the  jaw  and  also  close  to  its  origin,  and 
in  this  way  the  parts  which  lie  beneath  the  muscle,  external  ptery- 
goid, are  exposed, — the  zygomatic  and  spheno-maxillary  fossae,  with 
their  important  vascular  and  nervous  structures. 

The  zygomatic  fossa  is  that  space  which  is  limited  above  by 
the  prominent  horizontal  ridge  called  the  pterygoid  ridge  which  is 
found  upon  the  under  surface  of  the  great  wing  of  the  sphenoid  about 


SIDE  OF  THE  FACE. 


141 


opposite  the  zygoma.  The  floor  of  the  zygomatic  fossa  is  composed 
of  the  under  surface  of  the  great  wing  of  the  sphenoid  (base  of  the 
skull)  from  the  pterygoid  ridge  to  the  base  of  the  pterygoid  process, 
and  also  of  the  surface  of  the  external  plate  of  the  pterygoid  process. 
It  presents  the  foramen  ovale  and  the  foramen  spinosum. 


Fig.  74.— Pterygo-maxillary  Region.  External  pterygoid  muscle  cut  away, 
exposing  external  pterygoid  plate,  etc.  AT,  auriculo-temporal  nerve;  ID, 
Inferior  dental  nerve;  HI,  internal  maxillary  artery;  L,  lingual,  or  gustatory, 
nerve;  3I3I,  middle  meningeal  artery;  PI,  internal  pterygoid  muscle;  SM, 
superior  maxillary  (second  division  of  the  fifth)  nerve  passing  across  the 
spheno-maxillary  fossa. 

The  spheno-ma.xillary  fossa  is  the  narrow  perpendicular  space 
which  is  bounded  in  front  by  the  posterior  aspect  of  the  superior 
maxilla  and  behind  by  the  front  of  the  pterygoid  process.  Its  inner 
wall  is  formed  by  the  vertical  plate  of  the  palate  bone  and  consti- 
tutes a  part  of  the  lateral  wall  of  the  nasal  cavity.  Above,  this  space 
is  bounded  by  the  orbital  process  of  the  palate  bone  and  the  body  of 


142  HEAD  AND  FACE. 

the  sphenoid.  The  inner  wall  presents^  above,  the  spheno-jaalatine 
foramen,  through  which  it  communicates  with  the  nasal  cavity  and 
below  the  upper  opening  or  commencement  of  the  posterior  palatine 
canal.  Into  the  upper  part  of  this  fossa,  upon  its  posterior  wall, 
the  foramen  rotundum  opens;  above  and  internal  to  this  is  the 
opening  of  the  Vidian  canal.  The  anterior  wall  of  the  space  pre- 
sents the  commencement  of  the  infra-orbital  canal,  which  transmits 
the  second  or  superior  maxillary  division  of  the  fifth  nerve. 

Located  between  the  inner  surface  of  the  condyle  of  the  lower 
jaw  and  the  internal  lateral  ligament  is  the  first  part  of  the  internal 
maxillary  artery;  in  this  situation  the  vessel  gives  off  the  middle 
meningeal  branch,  which  passes  directly  upward  and  enters  the  skull 
through  the  foramen  spinosum.  The  middle  meningeal  artery,  at 
its  origin,  is  surrounded  by  the  two  roots  of  the  auriculo-temporal 
nerve;  these  two  roots  join  posteriorly  to  form  the  auriculo-temporal, 
which  passes  backward,  as  far  as  the  temporal  artery,  and,  after 
emerging  from  the  upper  part  of  the  parotid  gland,  ascends  in  front 
of  the  ear,  to  be  distributed  to  the  integument  of  the  temporal  region. 

A  little  in  front  and  to  the  inner  side  of  the  middle  meningeal 
artery  may  be  observed  the  inferior  maxillary  division  of  the  fifth 
nerve.  This  trunk  consists  of  a  large  sensory  root  and  a  smaller 
motor  root,  which  emerge  from  the  skull  through  the  foramen  ovale 
and  join  together  outside  this  opening,  just  below  the  base  of  the 
skull,  to  form  the  inferior  maxillary  division. 

The  inferior  maxillary  division  gives  off  two  temporal  branches, 
which  pass  upward  beneath  the  temporal  muscle,  and  two  large 
branches,  which  pass  downward  and  forward.  One  of  these,  the 
lingual  or  gustatory,  is  joined  below  by  the  chorda  tympani,  a  branch 
of  the  facial,  and  the  other,  the  inferior  dental,  enters  the  canal  on 
the  inner  surface  of  the  ramus  of  the  jaw  to  supply  the  lower  teeth. 
Attached  to  the  inner  posterior  aspect  of  the  inferior  maxillary  di- 
vision is  the  otic  ganglion;  it  is  located  just  below  the  foramen  ovale. 

In  the  upper  jDart  of  the  spheno-maxillary  fossa  is  seen  the  mid- 
dle, or  superior  maxillary,  division  of  the  fifth  nerve.  This  nerve 
leaves  the  skull  through  the  foramen  rotundum,  passes  forward,  across 
the  upper  part  of  the  spheno-maxillary  fossa  and,  as  the  infra-orbital, 
and  accompanied  by  the  terminal  branch  of  the  internal  maxillary 
artery,  enters  the  infra-orbital  canal,  and  is  finally  distributed  to 
the  skin  of  the  front  of  the  face,  below  the  orbit.  Suspended  from 
the  lower  border  of  the  middle  division,  as  it  passes  across  the  upper 


OPERATIONS  UPON  THE  FACE.  143 

part  of   the   spheno-m axillary  space,   is   JMeckcI's   oanglioii.   with   its 
descending  palatine  hranches,  etc. 

We  may  now  remove  rather  more  of  the  ramus  of  the  jaw  in 
order  to  expose  more  completely  the  internal  pterygoid  muscle.  This 
is  seen  to  arise  from  the  inner  surface  of  the  external  pterygoid 
plate,  and,  passing  downward,  backward,  and  outward,  is  attached 
to  the  inner  surface  of  the  angle  of  the  jaw.  Between  this  muscle 
and  the  inner  surface  of  the  ramus  of  the  jaw  are  the  inferior  dental 
nerve,  which  enters  the  canal  on  the  inner  surface  of  the  ramus,  and 
the  lingual,  which  is  joined  by  the  chorda  tympani.  The  internal 
lateral  ligament  of  the  jaw  may  also  be  seen  in  this  dissection. 

OPERATIONS  UPON  THE  FACE. 

Resection  of  the  Tipper  Jaw. — The  chief  danger  in  this  operation 
is  from  the  entrance  of  blood  into  the  larynx.  This  may  be  avoided 
by  previously  ligating  the  external  carotid  or  by  a  preliminary 
tracheotomy  and  the  use  of  a  Trendelenburg  tampon  cannula;  or  an 
ordinary  tracheotomy  tube  may  be  used,  in  this  latter  case  packing 
the  pharynx,  through  the  mouth,  with  a  gauze  pad.  The  operation 
may  be  done  without  a  preliminary  tracheotomy  by  operating  with 
the  patient  in  the  Eose  position,  the  head  hanging  over  the  end  of 
the  table,  so  that  the  field  of  operation  is  upon  a  lower  level  than 
the  larynx.  The  operation  may  also  be  done  with  the  patient  in  a 
semirecumbent  position,  using  incomplete  morphin-chloroform  nar- 
cosis, the  patient  being  but  partly  anaesthetized,  and  therefore  able 
to  cough  and  keep  the  larynx  clear  of  blood. 

The  incision  should  be  so  placed  as  to  avoid  Stenson's  duct. 

Weber's  Incision. — Eeaching  from  the  inner  angle  of  the  eye, 
the  incision  is  carried  down  alongside  of  the  nose  and  around  the 
ala  to  the  middle  line,  terminating  by  splitting  the  upper  lip.  To  this 
is  added  a  second  incision  reaching  from  the  inner  angle  of  the  eye, 
outward,  below  the  lower  margin  of  the  orbit.  This  second  incision 
should  pass  along  the  lower  edge  of  the  orbicularis  palpebrarum  in 
order  to  avoid  cutting  into  the  substance  of  this  muscle.  These  in- 
cisions penetrate  to  the  bone.  Branches  of  the  facial  nerve  are  not 
cut  in  making  the  incision.  The  flap  which  is  thus  marked  out  is 
reflected  outward,  and  should  be  raised  subperiosteally  if  the  char- 
acter of  the  disease  peraiits.  The  infra-orbital  vessels  and  nerve  are 
cut  when  the  flap  is  separated  from  the  anterior  surface  of  the  su- 
perior maxilla. 


lU 


HEAD  AND  FACE. 


Langenbeck^s  Incision. — A  flap,  its  lower  border  curved  with 
the  convexity  downward;,  is  raised.  The  incision  commences  at  the 
inner  angle  of  the  eye,  and  passes  down  alongside  of  the  nose  to  a 
point  below  the  level  of  the  ala,  as  far  as  the  attachment  of  the  upper 
lip  to  the  alveolar  process  of  the  superior  maxilla;  here  it  curves 
outward,  corresponding  to  a  line  drawn  from  the  ala  of  the  nose  to 


Fig.  75.— Resection  of  Upper  Jaw.    L,  Langenbeck  incision;  V,  Velpeau 
incision;  W,  Weber  incision. 


the  lower  border  of  the  lobe  of  the  ear,  and  is  then  carried  upward 
to  a  point  over  the  prominence  of  the  cheek-bone.  This  incision 
does  not  divide  the  lip,  but  it  will  be  necessary  later  to  separate 
the  lip  from  its  attachment  to  the  jaw-bone.  It  divides  some  branches 
of  the  facial  nerve,  which  is  a  disadvantage.  The  front  surface  of 
the  bone  is  exposed  by  reflecting  the  flap  upward,  subperiosteally,  if 


OPERATIONS  UPON  THE  FACE. 


145 


the  conditions  permit.  In  raisino-  the  flap  from  the  bone  the  infra- 
orbital vessels  and  nerve  are  divided. 

In  making  either  of  these  incisions  the  facial  artery  is  divided 
and  must  be  clamped  and  ligated. 

After  the  soft  parts  have  been  detached  from  the  bone  the  carti- 
lage of  the  nose  is  separated  from  the  nasal  notch,  and  the  soft  parts. 


Fig.  76. — Resection  of  Upper  Jaw.  When  it  is  desired  to  leave  the  major 
part  of  the  malar  bone,  the  line  of  section  through  the  bone  should  be  as 
Indicated  upon  the  right  side  of  the  skull.  If  the  malar  bone  is  to  be  removed 
together  with  the  superior  maxillary,  the  section  through  the  bone  should  be  as 
is  represented  upon  the  left  side  of  the  skull,  the  line  of  division  passing  through 
the  frontal  process  of  the  malar  and  the  zygoma. 


corresponding  to  the  lower  margin  of  the  orbit,  raised  from  the  bone, 
and  the  tarso-orbital  fascia  cut  along  the  margin  of  the  orbit.  The 
floor  of  the  orbit  being  thus  exposed,  the  contents  of  the  orbit  are 
raised  out  of  the  way  with  a  blunt  retractor.  We  are  then  ready  to 
cut  through  the  nasal  process  of  the  superior  maxillary.  This  di- 
vision extends  from  the  margin  of  the  nasal  notch,  across  the  nasal 
process,  as  far  as  the  lacrymal  groove  or  fossa.     It  is  necessary  to 

10 


146  HEAD  AND  FACE. 

avoid  injury  to  the  lacrymal  sac^  the  upper  expanded  part  of  the 
lacrjonal  canal,  which  is  lodged  in  the  lacrymal  depression  npon  the 
lacrymal  bone.  The  division  of  this  process  of  bone  may  be  accom- 
plished with  a  chisel,  or  a  hole  may  be  made  in  the  lacr5^mal  bone, 
which  is  very  thin,  just  in  front  of  the  lacrymal  sac,  and  a  Gigli  saw 
introduced  through  the  orbit  and  around  the  process,  bringing  its 
end  out  through  the  nasal  notch;  the  Gigli  saw  is  carried  around 
the  bone  with  a  loop  of  silk  in  a  curved  needle.  Probably  a  chisel 
is  more  convenient  for  this  part  of  the  operation. 

We  may  then  proceed  to  the  next  step  of  the  operation,  which 
consists  in  separating  the  jaw  from  its  attachment  to  the  malar  bone. 
This  may  be  done  with  a  chisel  or  with  a  G-igli  saw.  The  line  of 
division  extends  through  the  maxillary  process  of  the  malar  bone 
into  the  anterior  end  of  the  spheno-maxillary  fissure.  If  this  section 
is  made  with  a  Gigli  saw,  the  instrument  may  be  carried  around  the 
bone  with  a  loop  of  strong  silk  in  a  large,  full-curved  needle.  The 
contents  of  the  orbit  being  well  retracted,  the  needle  is  passed  into 
the  orbit,  through  the  spheno-maxillary  fissure,  and  then  out  through 
the  zygomatic  fossa,  emerging  upon  the  face  below  the  malar  process ; 
the  suture  is  then  pulled  through,  drawing  the  saw,  which  thus  sur- 
rounds the  malar  bone  at  its  conjunction  with  the  superior  maxillary, 
after  it;  the  division  may  then  be  readily  made.  If  it  is  desired  to 
take  the  malar  bone  away  in  addition  to  the  superior  maxillar)^,  the 
needle,  after  entering  the  spheno-maxillary  fissure,  as  above  described, 
should  be  made  to  traverse  the  temporal  fossa,  appearing  above  the 
upper  border  of  the  malar  bone,  so  as  to  surround  its  frontal  process ; 
after  this  process  has  been  divided  the  zygomatic  arch  may  be  cut 
through  with  the  chisel,  thus  separating  the  malar  bone  from  its 
connection  with  the  temporal  bone. 

We  are  then  ready  to  make  the  division  through  the  hard  palate ; 
this  is  best  done  as  the  last  step  of  the  operation,  after  the  other 
connections  have  been  severed  on  account  of  the  hemorrhage  into 
the  mouth.  Before  dividing  the  hard  palate  the  muco-periosteal  layer, 
which  covers  it,  is  detached.  An  incision  is  made  in  the  muco- 
periosteal  covering  of  the  hard  palate,  commencing  anteriorly  just 
behind  the  incisor  teeth;  this  is  carried  back  along  the  side  of  the 
hard  palate,  close  to  the  alveolar  process,  as  far  as  the  attachment  of 
the  soft  palate  to  the  posterior  border  of  the  hard  palate.  With  a 
periosteum  elevator,  this  layer  is  separated  from  the  surface  of  the 
hard  palate,  as  far  as  the  middle  line ;  the  soft  palate  is  also  separated 


OPERATIONS  UPON  THE  FACE.  I47 

from  the  corresponding  half  of  the  posterior  border  of  the  hard  pal- 
ate. A  chisel  is  then  placed  in  the  middle  line  between  the  two  in- 
cisor teeth,  and  the  hard  palate  divided  down  the  middle  for  its 
whole  length.  It  is  probably  better,  in  some  cases,  to  accomplish 
this  division  with  a  saw.  For  this  purpose  we  nse  a  narrow  saw, 
which  is  introduced  into  the  nasal  cavity,  after  the  first  incisor  tooth 
of  the  jaw  which  is  to  be  excised  has  been  extracted,  sawing  through 
the  floor  of  the  nasal  cavity  from  above  downward  and  from  before 
backward. 

The  jaw-bone  is  now  free  except  for  its  attachment,  behind,  to 
the  palate  bone  and  to  the  pterygoid  plate  of  the  sphenoid.  The 
floor  of  the  orbit,  which  is  very  thin,  may  be  cut  through,  just  behind 
its  anterior  margin,  with  one  or  two  strokes  of  the  chisel,  this  line 
of  section  reaching  from  the  lacrymal  fossa  across  the  floor  of  the 
orbit  into  the  spheno-maxillary  fissure.  One  should  finally  see  that 
the  soft  parts  are  separated  from  the  facial  surface  of  the  bone,  well 
beyond  the  last  molar  tooth;  this  may  be  done  with  a  few  sweeps 
of  the  knife,  cutting  close  to  the  surface  of  the  bone. 

The  body  of  the  jaw  is  seized  with  a  strong  bone-forceps,  and, 
with  a  gradually  increasing  rocking  motion,  it  is  forcibly  wrenched 
from  its  remaining  attachment.  Usually  all  of  the  palate  bone, 
except  its  orbital  process,  comes  away  with  the  superior  maxilla  and 
there  is  left  remaining  a  part  of  the  orbital  surface  of  the  superior 
maxilla  sufficient  to  support  the  contents  of  the  orbit.  If  part  of 
the  pterygoid  process  comes  away  with  the  superior  maxillary,  the 
bone  will  still  be  held  by  some  of  the  muscles  which  arise  from  this 
process, — ^the  internal  and  external  pterygoids, — and  it  will  be  neces- 
sary to  divide  these  with  a  sweep  of  the  knife  before  the  bone  can  be 
removed. 

There  is  left  a  large  bloody  space,  but,  as  a  rule,  there  is  little 
or  no  hemorrhage,  owing  to  the  tearing  of  the  blood-vessels  in 
wrenching  the  bone  free.  The  infra-orbital  vessels  and  nerves  may 
be  seen  hanging  free  in  the  wound.  The  vessels,  which  may  bleed 
freely,  should  be  seized  at  once,  clamped,  and  tied,  and  the  nerve 
cut  short.  The  other  branches  of  the  internal  maxillary  artery  also 
are  exposed, — the  descending  palatine  and  spheno-palatine, — and 
these  should  also  be  clamped  and  tied. 

The  wound  may  now  be  irrigated  and  tamponed,  the  ends  of 
the  gauze  emerging  through  the  nostril.  The  incision  upon  the  face 
is  closed  with  inten-upted  silk  sutures,  but,  before  doing  this,  the  edge 


148  HEAD  AND  FACE. 

of  the  muco-periosteal  flap,  which  was  raised  from  the  surface  of  the 
hard  palate,  is  stitched  with  interrupted  silk  sutures  to  the  inner  side 
of  the  cheek  along  the  line  where  this  was  separated  from  the  alveolar 
process  of  the  superior  maxilla.  The  ends  of  these  sutures  are  left 
rather  long  and  presenting  into  the  mouth,  to  facilitate  their  removal 
later. 

During  the  operation  the  back  of  the  mouth  and  the  pharynx 
may  be  kept  clear  of  blood  with  gauze  pads  on  long  holders. 

Total  Resection  of  Both  Superior  Maxillae. — This  operation  is 
analogous  to  the  preceding. 

A  curved  incision,  passing  from  the  angle  of  the  mouth  outward 
and  upward  to  the  malar  bone  on  each  side,  or  a  double  Weber  in- 
cision, may  be  used. 

The  nasal  septum,  vomer,  is  divided  with  bone  scissors,  and  the 
soft  parts  as  a  whole,  including  the  nose,  are  detached  and  reflected 
upward,  or  if  a  double  Weber  incision  is  used  the  lateral  flaps  are 
separated  from  the  bone  and  reflected  outward. 

The  attachments  of  the  superior  maxillge  are  then  divided  as  in 
the  preceding  operation,  except  that  it  will  not  be  necessary  to  split 
or  cut  through  the  hard  palate,  as  this  is  taken  away  entirely.  If 
possible,  the  muco-periosteal  covering  of  the  hard  palate  should  be 
stripped  off  and  preserved;  this  is  done  by  separating  it,  with  an 
elevator,  through  a  curved  incision  which  penetrates  through  this 
layer  down  to  the  bone  and  which  is  placed  just  inside  the  line  of 
the  teeth.  The  soft  palate,  at  its  attachment  to  the  posterior  border 
of  the  hard  palate,  is  also  completely  separated.  Finally,  with  lion- 
jaw  forceps,  the  bone  is  forcibly  wrenched  free  as  in  the  preceding 
operation. 

The  soft  parts  are  brought  together  with  silk  sutures,  first  uniting 
the  edges  of  the  muco-periosteal  flap,  which  was  raised  from  the  hard 
palate,  to  the  inner  side  of  the  cheeks,  corresponding  to  the  line 
where  they  were  separated  from  the  alveolar  process. 

To  Drain  the  Antrum  of  Highmore.  Through  the  Tooth 
Socket. — Empyema  is  frequently  associated  with  carious  teeth. 
These  or  their  remaining  roots  may  be  extracted  and  an  opening 
made  into  the  antrum  by  gouging  out  the  alveolar  cavity,  which  is 
often  found  to  be  carious.  This  may  be  done,  as  a  rule,  with  a  sharp 
spoon  or  with  a  narrow  chisel.  The  chisel  should  be  directed  upward 
toward  a  point  corresponding  to  the  middle  of  the  lower  margin 
of  the  orbit.     Such  an  opening,  if  made  sufficiently  large,  provides 


OPERATIONS  UPON  THE  FACE.  149 

satisfactory  drainage  from  the  antrum.  A  strip  of  gauze  may  be 
introduced  to  drain  the  cavity  and  to  prevent  the  entrance  of  par- 
ticles of  food.  Tlie  opening  should  be  made  through  the  alveolus 
of  the  first  molar  tooth. 

Through  the  Anterior  Wall. — Drainage  may  be  established 
by  making  an  opening  through  the  front  wall  of  the  antrum.  The 
upper  lip  is  everted  and  the  mucous  membrane  cut  and  the  soft  parts 
separated  from  the  front  surface  of  the  bone  with  the  periosteum 
elevator.  The  front  wall  of  the  antrum  is  perforated  through  the 
canine  fossa  just  above  and  to  the  outer  side  of  the  canine  tooth. 
The  socket  of  this  tooth  is  marked  by  a  prominent  ridge. 

After  the  periosteum  has  been  stripped  off  the  bone  a  good- 
sized  opening  is  made  into  the  antrum  with  the  chisel  or  with  a 
strong,  sharp-pointed  perforator  or  with  a  drill.  The  instrument 
should  be  directed  upward  and  somewhat  backward  toward  the  floor 
of  the  orbit,  but  care  should  be  taken  to  avoid  entering  the  antrum 
abruptly  with  such  force  as  to  endanger  the  floor  of  the  orbit.  A 
drainage  tube  may  be  introduced  and  left  in  place  for  several  days 
until  the  drainage  opening  is  well  established. 

This  operation  may  well  be  combined  with  drainage  through  the 
tooth  socket  as  described  above.  Both  operations  may  be  done  with 
the  patient  in  the  Eose  position  or  with  partial  morphin-chloroform 
anaesthesia. 

Through  the  Lateral  Wall  oe  the  Nose. — Mikulicz  advises 
making  an  opening  in  the  lateral  wall  of  the  nose  just  below  the 
middle  of  the  inferior  turbinated.  This  may  be  done  with  a  sharp- 
pointed  perforator  somewhat  bent  upon  itself  near  the  end.  The 
bone  is  thin,  and  the  operation  is  readily  done  except  when  the  nasal 
cavity  is  narrow  or  the  inferior  turbinated  much  hypertrophied. 

Resection  of  Half  of  the  Lower  Jaw.- — The  incision  commences 
at  the  middle  of  the  chin  and  follows  along  the  lower  border  of  the 
body  of  the  jaw  as  far  as  the  angle,  whence  it  is  continued  upward 
along  the  posterior  border  of  the  ramus  as  high  as  the  lower  border 
of  the  lobe  of  the  ear  (one  may  cut  to  this  point  without  danger  of 
injuring  the  facial  nerve;  see  Fig.  138).  This  incision  for  its  whole 
extent  should  reach  to  the  bone.  There  may  be  added  in  front  a 
vertical  incision,  splitting  the  lower  lip  through  the  middle  line,  but 
this  is  usually  unnecessary.  The  facial  vessels  are  severed  in  making 
the  incision  along  the  lower  border  of  the  body  of  the  jaw-bone,  and 
these  must  be  clamped  and  tied. 


150  HEAD  AND  FACE. 

If  the  glands^  etc..  in  the  submaxillary  region  are  diseased,  in- 
stead of  the  above-described  incision  one  may  be  made  which  com- 
mences anterior!}^,  in  the  middle  line,  at  the  lower  border  of  the 
jaw,  from  which  point  it  passes  backward  and  somewhat  downward 
across  the  submaxillary  triangle,  deviating  from  the  lower  border 
of  the  jaw  as  it  passes  backward,  as  far  as  the  anterior  border  of  the 
sterno-mastoid  muscle,  whence  it  is  turned  upward  toward  the  apex 
of  the  mastoid  process.  This  incision  passes  through  the  integu- 
ment and  the  platysma.  The  flap  which  is  thus  outlined  is  turned 
up  over  the  side  of  the  face,  and  we  are  then  enabled,  as  a  prelimi- 
nary step,  to  clear  out  the  submaxillary  triangle,  and  before  doing 
this  we  can,  if  desired,  easily  expose  and  ligate  the  external  carotid 
artery.  Some  surgeons  precede  the  operation  with  a  preliminary 
tracheotomy,  introducing  a  tampon  cannula;  or  an  ordinary  tube 
may  be  introduced  and  the  pharynx  tamponed  through  the  mouth. 
These  measures  eliminate  the  danger  of  blood  being  inspired  into  the 
trachea. 

After  having  cleaned  out  the  submaxillary  triangle,  if  this  has 
been  necessar}^,  the  soft  parts  are  separated  from  the  external  sur- 
face of  the  body  and  ramus  of  the  jaw,  back  as  far  as  the  angle,  work- 
ing close  to  the  surface  of  the  bone;  the  attachment  of  the  masseter 
is  thus  separated  from  the  ramus.  The  separation  of  the  masseter 
and,  in  fact,  the  soft  parts  from  the  body  of  the  bone  as  well,  may 
be  accomplished  with  a  periosteum  elevator,  occasionally  snipping 
with  the  knife.  It  is  desirable,  if  the  nature  of  the  condition  pres- 
ent permits,  that  is,  if  the  periosteum  is  not  diseased,  to  make  this 
separation  subperiosteally.  In  the  mass  of  soft  parts  which  is  raised 
from  the  out^  surface  of  the  ramus  of  the  jaw  are  included,  besides 
the  masseter  muscle,  the  parotid  gland  and  Stenson^s  duct,  the  facial 
nerve,  and  the  temporal  art-ery.  N"one  of  these  structures  are  injured 
if  the  operator  works  close  to  the  surface  of  the  bone.  Pinall}^,  with 
a  clean  cut,  the  cavity  of  the  mouth  is  entered,  incising  the  mucous 
membrane  close  to  the  anterior  border  of  the  ramus  and  along  the 
dental  margin  of  the  body  of  the  jaw  as  far  as  the  middle  line;  in 
this  way  the  outer  surface  of  the  lower  jaw,  including  the  teeth,  is 
laid  bare.  Anteriorly,  where  the  body  of  the  jaw  is  to  be  divided,  a 
tooth  is  extracted  and  the  floor  of  the  mouth,  close  to  the  bone,  incised, 
so  that  the  Gigli  saw  may  be  carried  around  the  bone.  This  is  done 
with  a  loop  of  strong  silk  in  a  large  curved  needle.  This  division 
may    also    be    accomplished    with    a    metacarpal    saw.     The    section 


OPERATIONS  UPON  THE  FACE.  151 

through  the  body  of  the  jaw  in  front,  should,  if  possible,  be  made 
a  little  external  to  the  middle  line,  toward  the  side  of  the  disease,  in 
order  to  avoid  separating  the  genio-hyoid  and  genio-hyoglossus 
muscles  from  their  attachment  to  the  tubercles  on  the  inner  aspect  of 
the  symphysis  mentis.  If  these  muscles  are  separated  from  their 
attachment  to  the  jaw  there  is  a  great  tendency,  both  during  and 
after  the  operation,  for  the  tongue  to  drop  back  into  the  pharynx, 
closing  down  the  epiglottis  and  thus  greatly  interfere  with  the  patient's 
breathing. 

After  the  bone  has  been  divided  anteriorly  its  free  end  is  seized 
with  a  bone-forceps  and  drawn  outward,  thus  putting  the  structures 
attached  to  its  inner  surface  (floor  of  the  mouth)  on  the  stretch,  and 
they  are  then  divided  close  to  the  dental  margin  (teeth)  with  a 
scalpel.  When  the  condition  of  the  periosteum  permits,  if  the  peri- 
osteum is  not  diseasd,  these  parts  may  be  separated  from  the  inner 
surface  of  the  jaw  subperiosteally  with  the  elevator.  The  body  of 
the  bone,  still  firmly  grasped  with  the  bone-forceps  and  being  now 
freely  movable,  is  dragged  forcibly  downward  and  out  of  the  wound 
so  that  the  operator  can  reach  the  coracoid  process  to  which  the  tendon 
of  the  temporal  muscle  is  attached;  this  is  separated  with  a  knife, 
cutting  close  to  the  bone  and  avoiding  the  internal  maxillary  artery, 
and  the  bone  is  then  still  further  luxated.  Behind,  attached  to  the 
inner  surface  of  the  ramus  of  the  jaw,  at  the  angle,  is  the  internal 
pterygoid  muscle;  this  is  cut  away  close  to  the  surface  of  the  bone. 

The  inferior  dental  vessels  and  nerves  enter  the  jaw-bone  through 
the  inferior  dental  canal  on  the  inner  surface  of  the  ramus;  these 
structures  may  be  cut  or  torn,  but  before  being  cut  they  should  be 
grasped  with  an  artery  forceps;  later  the  vessels  are  tied  and  the 
forceps  removed,  liberating  the  nerve.  If  the  inferior  dental  should 
bleed  in  the  sawn  surface  of  the  remaining  half  of  the  bone  this  may 
be  stopped  by  plugging  the  orifice  of  the  canal  with  a  strand  of  catgut. 
'  The  flap  of  soft  parts  is  drawn  forcibly  upward,  and  the  bone, 
still  held  with  the  bone-forceps,  dragged  downward;  so  that  the 
outer  wall  of  the  capsule  of  the  temporo-maxillary  joint  may  be 
reached  with  the  point  of  a  sharp  loiife  and  incised;  the  tendon  of 
the  external  pterygoid,  which  is  attached  to  the  front  of  the  neck  of 
the  condyle,  is  likewise  divided.  In  cutting  these  structures  the  knife 
is  kept  applied  close  to  the  surface  of  the  bone  in  order  to  avoid  the 
internal  maxillary  and  the  temporal  arteries.  The  bone  may  now 
be  readily  twisted  out  of  its  socket. 


152  HEAD  AND  FACE. 

If  it  should  be  necessary  to  separate  the  muscles  of  the  tongue 
from  their  attachment  to  the  symphysis  of  the  jaw,  a  thick  silk  suture 
should  be  previously  passed  through  its  tip,  to  be  used  as  a  tractor 
to  prevent  its  being  drawn  backward  into  the  pharynx  and  closing 
the  larynx  and  interfering  with  respiration.  It  is  probably  advisable 
to  introduce  such  a  suture  in  all  cases. 

The  cut  edge  of  the  mucous  membrane  which  was  separated  from 
the  inner  aspect  of  the  jaw-bone  is  now  accurately  sutured  to  the 
corresponding  edge  of  the  mucous  membrane  which  was  separated 
from  the  outer  aspect,  except  for  a  short  space  behind,  through  which 
the  cavity  of  the  mouth  is  drained;  these  sutures  should  be  of  silk, 
knotted  on  the  inside  of  the  mouth,  and  the  ends  left  sufficiently  long 
to  allow  of  their  ready  removal  later. 

'  The  edges  of  the  skin  are  approximated  with  interrupted  sutures 
except  at  the  posterior  part  where  the  drain  emerges. 

For  the  purpose  of  facilitating  drainage,  the  wound  is  loosely 
packed  with  iodoform  gauze,  reaching  into  the  cavity  of  the  mouth. 
This  may  be  removed  after  a  few  days,  when  a  sinus  is  established 
through  which  all  secretions  from  the  mouth  may  find  exit. 

Resection  of  Half  of  the  Body  of  the  Lower  Jaw. — A  strong, 
thick  suture  is  passed  through  the  tongue  for  use  as  a  tractor,  if  this 
becomes  necessary.  An  incision  is  made  along  the  lower  border  of 
the  body  of  the  jaw  from  the  middle  line  in  front  to  the  junction 
of  the  body  and  ramus  just  beyond  the  last  molar,  behind;  this 
incision  penetrates  to  the  bone.  In  many  cases  the  facial  artery, 
where  it  curves  over  the  lower  border  of  the  body  of  the  jaw,  just 
in  front  of  the  masseter,  is  divided ;  but  frequently  this  may  be  avoided. 
If  the  vessel  is  cut  it  must  be  clamped  and  ligated.  There  may  be 
added  anteriorly  a  vertical  incision  which  splits  the  lower  lip  in  the 
middle  line ;  but,  as  a  rule,  this  is  unnecessary,  and  should  be  avoided. 

With  the  elevator  or  knife,  working  close  to  the  surface  of  the 
bone,  the  soft  parts  are  separated  from  the  outer  surface  of  the  body 
of  the  jaw,  finally  cutting  through  the  mucous  membrane  close  to 
the  teeth  and  thus  entering  the  mouth  and  exposing  the  outer  surface 
of  the  body  of  the  bone  and  the  teeth. . 

The  floor  of  the  mouth  is  now  perforated,  anteriorly,  near  the 
middle  line,  close  to  the  inner  surface  of  the  bone,  and,  after  ex- 
tracting a  tooth,  the  Gigli  saw  is  introduced,  being  carried  around 
the  jaw  with  a  loop  of  silk  in  a  large  curved  needle,  and  the  bone 
is  then  sawn  through;  this  section  should  be  made  to  the  side  of 


OPERATIONS  UPON  THE  FACE.  153 

the  middle  line  in  order  not  to  disturb  the  attachment  of  the  muscles 
of  the  tongue  to  the  S3^mphysis.  If  the  end  of  the  divided  bone 
■•bleeds,  this  may  be  controlled  by  plugging  the  orifice  of  the  canal 
which  contains  the  nutrient  artery.  The  end  of  that  half  of  the 
bone  which  is  to  be  excised  is  seized  with  the  bone-forceps  and  drawn 
strongly  outward,  thus  putting  the  soft  parts  attached  to  its  inner 
surface  (floor  of  the  mouth)  upon  the  stretch.  These  parts  are  sep- 
arated from  the  inner  surface  of  the  bone  as  far  back  as  the  Junction 
of  the  body  with  the  ramus — beyond  the  last  molar  tooth.  This  may 
be  done  bluntly  with  an  elevator,  separating  subperiosteally,  or,  if 
this  is  contra-indicated  on  account  of  the  character  of  the  disease, 
the  soft  parts,  including  the  mucous  membrane,  may  be  simply  cut 
away  from  the  bone  with  the  knife.  After  having  thus  stripped  the 
body  of  the  bone  of  its  soft  parts,  both  upon  its  outer  and  its  inner 
or  buccal  surface,  the  saw  is  applied  just  behind  the  last  molar  tooth 
and  the  bone  cut  through.  This  may  be  done  with  the  Gigli  saw  or 
with  a  narrow  metacarpal  saw.  While  the  bone  is  being  divided 
it  should  be  drawn  well  downward  with  the  bone-forceps. 

Hemorrhage  from  the  cut  surface  of  the  bone  is  controlled  with 
a  plug  of  catgut,  which  is  packed  into  the  orifice  of  the  dental  canal. 

The  mucous  membrane,  which  was  separated  from  the  outer  sur- 
face of  the  segment  of  bone  which  has  been  resected,  is  sutured  to  the 
cut  edge  of  the  parts  which  were  separated  from  the  inner  surface 
of  the  bone.  This  closes  in  the  cavity  of  the  mouth,  and  may  be 
done  with  interrupted  silk  sutures  tied  within  the  mouth,  the  ends 
being  left  long  so  that  they  may  be  readily  removed. 

The  incision  in  the  skin  is  closed  in  part,  leaving  the  posterior 
end  open  for  drainage.  It  is  probably  wise,  in  most  cases,  to  leave 
a  small  opening  through  the  mucous  membrane  also,  so  that  the 
cavity  of  the  mouth  may  be  drained;  in  this  case  the  gauze,  which 
is  introduced  into  the  posterior  portion  of  the  skin  incision,  is  packed 
into  the  mouth. 

Resection  of  the  Entire  Body  of  the  Lower  Jaw. — This  is  anal- 
ogous to  the  preceding  operation,  but  special  care  must  be  exercised 
to  guard  against  the  tongue  dropping  back  into  the  pharynx  after 
the  attachment  of  the  muscles,  which  pull  it  forward,  have  been  sep- 
arated from  the  inner  surface  of  the  symphysis.  This  accident  may 
be  prevented  by  passing  a  ligature  through  the  tip  of  the  tongue  by 
which  traction  may  be  made.  There  is  also  considerable  danger  of 
the  tongue  dropping  back   and  obstructing  the  breathing  after  the 


154  HEAD  AND  FACE. 

operation,  and  this  accident  might  easily  cause  the  death  of  the  pa- 
tient; so  that  the  tractor  should  be  allowed  to  remain  in  the  tongue 
and  fixed  outside. 

The  jaw-bone  is  divided  in  the  middle  line,  and  then  each  half 
is  resected  separately  as  described  in  the  preceding  operation. 

Resection  of  Part  of  the  Body  of  the  Lower  Jaw  in  Continuity. 
Fkom  Within  the  Mouth. — Precautions  must  be  taken  to  prevent 
blood  entering  the  larynx  during  the  operation  (see  "Eesection  of 
the  Upper  Jaw,"  etc.).  A  mouth-gag  is  introduced  and  an  incision 
is  made  through  the  mucous  membrane  on  either  side  of  the  teeth,  and 
the  soft  parts  separated  from  the  inner  and  outer  surfaces  and  from 
the  lower  border  of  the  segment  of  the  jaw-bone  that  is  to  be  excised, 
with  an  elevator.  A  tooth  is  then  extracted  and  the  Grigli  saw  passed 
around  the  bone  with  a  loop  of  silk  in  a  large  curved  needle  and  the 
bone  divided;  this  procedure  is  repeated  at  the  other  end  of  the  seg- 
ment of  bone  which  is  to  be  excised.  The  hemorrhage  from  the  cut 
ends  of  the  bone  is  controlled  by  a  plug  of  catgut  packed  into  the 
dental  canal.  The  soft  parts  may  be  separated  from  the  surface 
of  the  bone  subperiosteally,  as  above  described,  but  in  most  cases  this 
is  not  permissible  on  account  of  the  character  of  the  disease.  After 
removal  of  the  segment  of  bone  the  edges  of  the  mucous  membrane 
may  be  brought  together,  at  least  in  part,  by  interrupted  silk  sutures. 
A  small  opening  may  be  made  externally  through  the  skin  for  drainage. 

If  the  anterior  portion  of  the  body  is  resected,  necessitating  the 
separation  of  the  tongue  muscles  from  the  symphysis,  proper  meas- 
ures must  be  taken  to  guard  against  the  tongue  dropping  back  upon 
the  epiglottis  and  larynx.  The  operation  done  from  within  the 
mouth  is  ordinarily  rather  disadvantageous,  as  it  is  rather  difficult  to 
properly  drain  the  wound  afterward. 

From  Without. — ^An  incision  is  made  along  the  lower  border 
of  the  body  of  the  bone  corresponding  to  that  part  of  the  bone  which 
is  to  be  resected  and  reaching  down  to  the  surface  of  the  bone.  Usually 
it  is  not  necessary  to  split  the  lower  lip.  The  soft  parts  are  separated 
from  the  outer  surface  of  the  body  of  the  bone  with  the  elevator,  if 
permissible  subperiosteally,  and  the  mucous  membrane  then  incised 
close  to  the  teeth,  thus  opening  into  the  mouth.  Corresponding  to 
the  points  at  which  the  bone  is  to  be  divided  the  teeth  are  extracted 
and  incisions  made  in  the  floor  of  the  mouth  close  to  the  bone  to  allow 
the  passage  of  the  Gigli  saw;  this  is  carried  around  the  bone  with 
a  loop  of  silk  in  a  full  curved  needle  and  the  bone  then  divided.     The 


OPERATIONS  UPON  THE  FACE. 


155 


segment  of  bone,  wliich  has  been  thus  loosened  and  to  the  inner 
aspect  of  which  the  soft  parts  of  the  floor  of  the  mouth  are  still  at- 
tached, is  seized  with  the  bone-forceps,  and  the  soft  parts  (mucous 
membrane  and  muscles  of  the  floor  of  the  mouth)  are  then  separated 
with  the  elevator  or  cut  with  the  knife  close  to  the  surface  of  the 
bone  and  near  its  alveolar  margin. 

Hemorrhage  from  the  bone  may  be  controlled  by  plugging  its 
nutrient  canal  with  a  piece  of  catgut. 


Incision   for  Resection  of  the   Temporo-maxillary   Joint. 


The  mucous  membrane,  which  was  separated  from  the  outer  sur- 
face of  the  resected  segment,  is  united  to  that  which  was  separated 
from  the  inner  surface  with  several  interrupted  silk  sutures,  tied 
within  the  mouth,  in  this  way  closing  in  the  cavity  of  the  mouth. 
The  external  wound  is  partly  closed  and  drained. 

If  the  part  resected  corresponds  to  the  anterior  portion  of  the 
body  of  the  jaw-bone,  it  is  desirable  to  secure  the  tongue  by  passing 
a  silk  suture  through  its  tip. 


156  HEAD  AND  FACE. 

Resection  of  Part  of  the  Body  of  the  Lower  Jaw  (Not  Through 
Entire  Thickness,  Not  in  Continnity). — Practically  as  described  in 
the  preceding  operation,  working  either  from  within  the  mouth  or 
without.  The  operation  consists  in  resecting  the  diseased  part  of 
the  bone  and  leaving  a  portion  of  the  hodj,  of  greater  or  less  thick- 
ness, as  a  bridge  to  preserve  the  continuity  of  the  bone  and  prevent 
deformity,  and  to  facilitate  the  application  of  an  apparatus.  The 
removal  of  the  bone  may  be  effected  with  a  chisel  or  with  the  cutting 
bone-forceps.    This  operation  is  but  seldom  practiced. 

Resection  of  Temporo-maxillary  Articulation. — This  operation 
consists,  as  a  rule,  in  the  extirpation  of  the  condyle  of  the  lower  jaw. 
The  interarticular  cartilage  and  the  glenoid  cavity  are  not  interfered 
with  in  most  cases.  The  operation  is  performed  for  ankylosis  and 
disease  of  the  joint.  It  may  be  necessary  to  resect  the  joint  on  both 
sides.  An  angular  incision  is  employed.  The  descending  arm  com- 
mences at  the  lower  border  of  the  zygoma  about  three-fourths  inch 
anterior  to  the  tragus  and  passes  downward  for  a  distance  of  about 
one  inch.  This  incision  lies  in  front  of  the  temporal  artery  and 
should  not  reach  low  enough  to  injure  Stenson's  duct  or  the  facial 
nerve.  These  latter  structures  rest  upon  the  masseter  muscle  and 
pass  from  behind  forward  below  and  parallel  with  the  zygoma.  Prom 
the  upper  end  of  the  vertical  incision  another  is  carried  forward 
along  the  lower  border  of  the  zygomatic  arch  for  a  distance  of  from 
one  and  one-half  to  two  inches.  The  flap,  consisting  of  skin  and 
fat,  is  reflected  downward  and  strongly  retracted,  exposing  the  upper 
part  of  the  masseter  muscle.  With  a  blunt  hook  the  posterior  edge 
of  the  wound,  including  the  anterior  margin  of  the  parotid  gland 
and  temporal  artery,  etc.,  is  retracted  backward. 

The  joint  is  exposed  by  detaching  the  masseter  muscle  from  the 
lower  border  of  the  zygoma  to  a  sufficient  extent  with  the  periosteum 
elevator.  The  capsule  is  incised  in  a  vertical  direction  and  also  de- 
tached with  the  elevator.  The  condyle  is  thus  exposed  and  may  be 
removed  by  dividing  the  neck  close  to  the  articular  surface  with  the 
chisel  or  Gigli  saw.  The  condyle  is  seized  with  small  bone-forceps 
and  any  remaining  soft  parts  cut  close  to  the  bone  and  the  condyle 
thus  removed.  It  is  desirable  to  leave  as  much  of  the  tendon  of  the 
external  pterygoid  attached  to  the  neck  of  the  bone  as  possible.  It 
is  advisable  in  most  cases,  especially  of  disease,  to  establish  temporary 
drainage  by  leaving  a  thin  strip  of  gauze  in  the  wound.  The  in- 
cision is  closed  except  where  the  drain  emerges. 


OPERATIONS  UPON  THE  FACE.  157 

Division  of  the  Second  and  Third  Branches  of  the  Trifacial 
Nerve  at  the  Base  of  the  Skull  (Kronlein's  Modification  of  Llicke's 
Operation). — This  operation  consists  in  exposing  the  second  and 
third  divisions  of  the  fifth  nerve  as  they  emerge  from  the  skull  and 
dividing  them  or  twisting  them  free  from  their  origin. 

An  incision  marking  out  a  rounded  skin-flap,  with  its  convexity 
downward  and  its  base  corresponding  to  the  upper  border  of  the 
zygomatic  arch,  is  made.  It  commences  anteriorly,  one  finger's  breadth 
behind  the  external  angular  process,  and  terminates  behind,  just  in 
front  of  the  tragus  (see  Fig.  68).  This  flap,  which  consists  of  the 
skin  and  subcutaneous  fascia,  is  raised  from  the  deep  fascia  covering 
the  parotid  gland  and  masseter  muscle,  and  is  reflected  upward,  thus 
exposing  the  arch  of  the  zygoma  and  the  lower  portion  of  the  tem- 
poral fascia,  which  is  attached  to  the  upper  border  of  the  arch.  The 
incision  does  not  reach  low  enough  to  injure  the  facial  nerve  or  Sten- 
son's  duct.  Bleeding  points  are  clamped  and  ligated  as  the  opera- 
tion progresses. 

The  temporal  fascia  attached  to  the  upper  border  of  the 
z5'gomatic  arch  is  incised  along  this  border  of  the  arch,  and  the  arch 
sawn  through :  first,  posteriorly  and  then  anteriorly.  Before  mak- 
ing this  division  of  the  arch,  holes  should  be  drilled  for  the  purpose 
of  wiring  the  detached  segment  in  position  later.  In  dividing  the 
arch  anteriorly  it  is  necessary  to  get  well  forward  so  as  to  include  as 
much  of  the  length  of  the  arch  as  possible;  the  line  of  division  should 
not  be  from  above  directly  downward,  but  from  above  obliquely  down- 
ward and  forward.  This  segment  of  the  arch,  carrying  the  attached 
masseter  muscle  with  it,  is  reflected  downward,  exposing  the  coracoid 
process  of  the  ramus  of  the  lower  jaw  and  the  attached  temporal 
tendon.  This  process,  after  making  drill-holes  for  subsequent  wiring, 
is  cut  away,  the  line  of  section  extending  from  the  deepest  part  of 
the  sigmoid  notch  obliquely  downward  and  fonvard  so  as  to  include 
practically  all  that  part  of  the  ramus  which  corresponds  to  the  attach- 
ment of  the  temporal  tendon.  This  segment  of  bone,  carrying  the 
temporal  tendon,  is  reflected  upward,  and  held  thus  with  a  retractor. 
The  external  pterygoid  muscle,  and  the  internal  maxillary  artery 
which  passes  obliquely  across  its  outer  surface,  may  now  be  recognized. 
It  is  well  to  tie  the  vessel  double  and  cut  it.  With  the  elevator  tlie 
attachment  of  the  external  pterygoid  is  separated  from  the  under 
surface  of  the  great  wing  of  the  sphenoid  and  drawn  downward.  The 
finger  is  introduced  into  the  space  above  the  upper  border  of  the 


158  HEAD  AND  FACE. 

muscle  and  is  joassed  inward  close  to  the  under  surface  of  the  bone 
(base  of  the  skull),  feeling  for  the  posterior  sharp  edge  of  the  external 
pterj'goid  plate  and  searching  for  the  foramen  ovale,  which  is  directly 
behind  and  a  little  external  to  the  root  or  base  of  the  pterygoid 
process,  external  pterygoid  plate.  We  should  recognize  the  trunk  of 
the  inferior  maxillary  as  it  emerges  from  the  foramen  ovale;  directly 
behind  this,  the  middle  meningeal  artery,  surrounded  by  the  two  roots 
of  the  auriculo-temporal  nerve,  is  seen  passing  upward  to  enter  the 
skull  through  the  foramen  spinosum  (see  Fig.  74).  The  inferior 
maxillary  division  is  seized  with  a  hook  and  drawn  forward  and  cut, 
and  then  the  stump,  gTasped  with  a  forceps,  is  twisted  free  from  its 
origin  at  the  Gasserian  ganglion.  Usually  the  motor  root  is  grasped 
at  the  same  time  and  included  with  it.  We  then  penetrate  into  the 
spheno-maxillary  fossa,  and  in  the  upper  part  of  this  cavit}^,  the 
superior  maxillary,  or  second,  division  of  the  fifth  nerve,  just  before  it 
enters  the  infra-orbital  canal,  is  seized  with  the  hook  and  drawn  out 
and  cut,  and  then  likewise  twisted  away  from  the  Gasserian  ganglion. 
The  Eustachian  tube  is  located  close  to  the  inner  side  of  the  inferior 
maxillary  nerve,  and,  therefore,  as  soon  as  this  trunk  of  the  nerve  is 
accessible,  one  should  not  penetrate  deeper  into  the  wound  for  fear  of 
injuring  the  Eustachian  tube  and  causing  infection  of  the  wound. 

The  coracoid  process  is  reunited  to  the  ramus  of  the  jaw  with 
a  wire  suture  and  the  segment  of  the  zygomatic  arch  is  likewise 
replaced  and  wired.     The  skin  incision  is  then  closed. 

Operations  upon  the  Peripheral  Branches  of  the  Trifacial  Nerve. 
— The  supraorbital,  infraorbital,  inferior  dental  and  lingual  branches 
are  sometimes  attacked  for  the  relief  of  pain. 

The  supra-orbital  and  infra-orbital  branches  may  be  exposed 
through  an  incision  above  or  below  the  orbit. 

The  inferior  dental  may  be  reached  through  an  incision  in  the 
side  of  the  mouth,  reaching  from  behind  the  upper  to  behind  the 
lower  last  molar  tooth.  The  finger  is  inserted,  through  the  incision, 
between  the  internal  pterygoid  muscle  and  ramus  of  the  jaw  and  the 
spine  that  marks  the  orifice  of  the  inferior  dental  canal  is  recognized. 
The  nerve  is  secured  with  a  blunt  hook  just  before  it  enters  the  canal, 
and  is  drawn  out  of  the  wound  and  may  then  be  stretched,  divided, 
etc.,  or  it  may  be  exposed  by  trephining  the  external  surface  of  the 
ramus  of  the  jaw  midway  between  its  anterior  and  posterior  borders 
and  upon  a  level  with  the  crown  of  the  last  molar  tooth.  The  nerve 
is  thus  exposed  just  before  it  enters  the  canal. 


OPERATIONS  IPON  THE  FACE.  159 

The  lingual  (gustator}')  nerve  may  be  divided  for  relief  of  pain 
in  inoperable  cancer  of  the  tongue.  The  nerve  is  exposed  through  an 
incision  in  the  floor  of  the  mouth  close  to  the  side  of  the  tongue  and 
opposite  to  the  last  molar  tooth.  The  nen-e  is  hooked  out  of  the  in- 
cision and  a  portion  of  its  length  resected.  The  nerve  may  also  be 
exposed  by  trephining  the  ramus  of  the  jaw  as  described  above  for 
exposure  of  the  inferior  dental.     It  is  found  just  a  little  anterior  to 


Fig.  78. — Points  of  Injection  of  the  Superior  and  Inferior  MaxiUary  Branches. 
2,  point  where  the  needle  is  introduced  to  reach  the  second  division;  3,  point 
for  the  third  division. 

the  inferior  dental  and  may  be  picked  up  and  a  piece  resected  in  this 
situation. 

Injection  of  the  Trunks  and  Peripheral  Branches  of  the  Trifacial 
Nerve. — Alcohol  is  injected  into  the  three  divisions  and  terminal 
branches  of  the  fifth  nerve  for  neuralgia — tic  douloureaux.  Eelief 
is  obtained  for  a  period  varying  from  a  few  months  to  a  number 
of  years. 

For  pain  corresponding  to  the  distribution  of  the  second  and 
third,  superior  and  inferior  maxillary,  divisions  the  injection  is  made 


160  HEAD  AND  FACE. 

down  into  or  around  the  trunks  as  they  emerge  from  their  foramina 
in  the  base  of  the  skull;  the  superior  as  it  emerges  from  the  foramen 
rotundum  and  the  inferior  as  it  emerges  from  the  foramen  ovale.  The 
first  division,  the  ophthalmic,  is  injected  through  the  orbital  cavity, 
but  this  is  very  hazardous. 

The  fluid  injected  is  composed  as  follows : — 

Cocain  hydrochloride   i^  per  cent. 

Alcohol    85  per  cent. 

Distilled  water 15  per  cent. 

Two  cubic  centimetres  of  the  fluid  are  used  for  each  division 
of  the  nerve  injected. 

An  all-glass  syringe  with  a  capacity  of  two  to  three  cubic  centi- 
metres and  a  needle  with  a  blunt  point,  about  six  to  seven  centimetres 
long,  and  with  a  calibre  of  1  mm.,  are  used.  The  needle  is  marked  in 
centimetres  to  indicate  the  depth  to  which  it  is  inserted. 

The  skin  corresponding  to  the  point  where  the  needle  is  to  be 
inserted  is  anaesthetized  by  injecting  a  weak  solution  of  cocain  and 
a  small  incision  then  made  with  the  point  of  the  knife  in  order  to 
permit  of  easy  introduction  of  the  blunt-pointed  needle.  A  blunt 
needle  with  a  sharp-pointed  stylet  may  be  used.  In  this  case  it  will 
not  be  necessary  to  make  the  little  incision  in  the  skin  to  permit 
the  introduction  of  the  needle.  After  the  needle  has  pierced  the  skin 
the  stylet  is  withdrawn  a  little  so  that  for  the  rest  of  its  course  the 
needle  penetrates  the  tissues  bluntly.  Strict  asepsis  should  eliminate 
the  danger  of  infection.  As  a  rule  there  is  little  or  no  complaint 
following  the  injection.  Several  injections  may  be  necessary  before 
relief  is  obtained.  The  danger  of  hemorrhage  is  slight;  usually  more 
or  less  ecchymosis  of  the  skin  is  seen  after  the  injection. 

Superior  Maxillary  Division". — A  line  is  carried  perpen- 
dicularly downward  continuous  with  the  posterior  border  of  the  frontal 
process  of  the  malar  bone ;  one-half  centimetre  behind  the  point  where 
this  line  strikes  the  inferior  border  of  the  zygoma  and  very  close  to 
this  (lower)  border  of  the  zygoma,  the  needle  is  introduced.  The 
needle  is  pushed  inward  and  slightly  upward  and  backward  to  a  depth 
of  five  centimetres.  The  point  of  the  needle  enters  the  upper  part 
of  the  spheno-maxillary  fossa  and  touches  or  is  very  close  to  the 
nerve  as  it  crosses  the  spheno-maxillary  fossa  before  it  enters  the 
infraorbital  canal  (see  Fig.  74).  The  needle  as  it  is  pushed  in 
may  strike  the  coronoid  process  of  the  inferior  maxilla  at  a  depth  of 


CONGENITAL  DEFORMITIES'  OF  THE  FACE.         161 

one  and  one-half  to  two  centimetres.  This  may  be  avoided  by  with- 
drawing the  needle  a  little  and  directing  it  a  trifle  more  anteriorly. 
At  a  depth  of  three  and  one-half  to  four  centimetres  the  needle  may 
strike  the  anterior  border  of  the  pterygoid  process.  The  needle  is 
withdrawn  a  trifle  and  its  direction  changed  a  little  more  anteriorly, 
when  it  will  pass  into  the  spheno-maxillary  fossa.  In  changing 
the  direction  of  the  needle  toward  tlie  front  when  it  strikes  an  ob- 
struction in  its  course,  care  should  be  taken  to  do  this  cautiously 
and  only  to  a  slight  degree.  There  is  danger  of  pushing  the  needle 
through  the  spheno-maxillary  fissure  into  the  orbit.  A  sudden  sharp 
pain  corresponding  to  the  area  supplied  by  the  nerve  results  if  the 
needle  touches  the  nerve.  Two  cubic  centimetres  of  the  alcoholic 
solution  is  injected  at  this  depth.  As  a  rule  the  fluid  is  not  injected 
actually  into  the  nerve-trunk,  but  into  the  tissues  immediately  ad- 
jacent and  reaches  the  nerve-trunk  by  diffusion. 

Inferior  Maxillary  Division. — The  needle  is  introduced  at 
a  point  two  and  one-half  centimetres  in  front  of  the  anterior  edge 
of  the  external  auditory  meatus  and  just  below  the  lower  border  of 
the  zygoma,  and  is  pushed  inward  and  a  little  backward  and  upward 
to  a  depth  of  four  centimetres  and  the  fluid  injected. 

Ophthalmic  Division. — ^The  needle  is  inserted,  according  to 
Patrick,  through  the  orbital  cavity.  It  passes  along  the  outer  wall 
of  the  orbit,  hugging  close  to  the  outer  wall  and  passing  between 
this  wall  and  the  lacrymal  gland.  At  a  depth  of  three  and  one-half 
to  four  centimetres  the  injection  is  made.  It  would  seem  to  be  an 
extra  hazardous  procedure  to  inject  the  first  division.  The  first 
division  is  not  so  frequently  affected  and  relief  might  be  obtained 
by  the  less  dangerous  plan  of  injecting  the  supraorbital  branch  as 
it  emerges  from  its  foramen. 

The  end  branches  of  the  fifth  nerve  may  be  injected  as  they 
emerge  upon  the  face  at  the  supraorbital,  infraorbital,  and  mental 
foramina. 

CONGENITAL  DEFORMITIES  OF  THE  FACE. 

The  Development  of  the  Face. — About  the  twelfth  day  the 
arrangement  of  the  head  end  of  the  embryo  is  quite  simple.  A  cross- 
section  shows  it  to  consist  of  two  tubes,  one  being  situated  in  front 
of  the  other.  The  anterior  is  the  blind,  head  end  of  the  alimentary 
tube, — the  future  pharynx.  The  posterior  is  the  enlarged  neural  tube 
which  is  later  developed  into  the  brain.     The  anterior  wall  of  this 


163  HEAD  AND  FACE. 

Tipper^  head  end  of  the  alimentan^  tube  is  called  the  "oral  plate/' 
and  marks  the  location  of  the  future  mouth  and  face.  A  sagittal 
section  will  also  show  this  relationship,  and  further  that  the  neural 
tube  not  only  lies  behind  the  alimentary  tube,  but  also  arches  for- 
ward above  the  upper  end  of  the  latter  like  a  hood,  overriding  it 
anteriorly.  This  upper  part  of  the  neural  tube,  which  projects  forward 
over  the  end  of  the  alimentary  tube,  is  called  the  vesicle  of  the  fore- 
brain. 

In  the  third  week  there  may  be  seen,  upon  either  side  of  the 
head  end  of  the  embryo,  four  transverse  plates  or  ribs  of  tissue  which 


Fig.  79. — Transverse  Section  of  the  Head  End  of  an  Embryo  Twelve  Days  Old. 
A,  alimentary  tube;  2V^,  neural  tube;  NC,  notochord;  OP,  oral  plate. 

are  separated  from  one  another  by  deep  fissures,  or  clefts.  The 
thickened  plates  are  called  visceral  arches,  and  the  intervening  spaces, 
or  fissures,  visceral  clefts.  Within  the  alimentary  tube,  upon  its 
inner  aspect,  there  may  be  seen  corresponding  arches  and  clefts.  These 
arches  are  simply  thickenings  or  ribs  in  the  lateral  walls  of  the  head 
end  ("scJilund"  pharynx)  of  the  alimentary  tube.  Each  mass  con- 
sists of  mesoblast,  covered  upon  its  outer  surface  by  the  epidermic 
layer,  which  covers  the  whole  exterior  of  the  body,  and  upon  its 
inner  surface  by  the  endodermic  layer,  which  lines  the  whole  inner 
surface  of  the  alimentary  tube.  Between  the  arches,  at  the  bottom 
of  any  two  opposed  clefts,  the  wall  of  tissue  is  extremely  thin ;  consists 
practically  of  the  outer  (epidermic)  and  the  inner  (endodermic) 
layers.     The  uppermost  of  these  visceral  arches,  that  concerned  in 


CONGENITAL  DEFORMITIES  OF  THE  FACE. 


163 


the  formation  of  the  face,  is  the  thickest.  It  extends  forward,  and 
in  front,  where  it  is  narrower,  unites  in  the  middle  line  with  its 
fellow  of  the  opposite  side,  to  form  the  mandibular  arch,  which  repre- 
sents the  future  lower  jaw.  The  second  arch  is  less  prominent  than 
the  first,  and  as  it  passes  forward  is  directed  somewhat  upward.  This 
second  arch  does  not  reach  as  far  as  the  middle  line.  The  third  and 
fourth  arches  are  still  less  prominent  and  still  shorter.  These  lower 
three  arches  do  not  join  with  their  fellows  across  the  middle  line  in 
front,  but  are  continued  into  the  plate  of  tissue  which  forms  the  front 
wall  of  the  (schlund)  pharynx.     From  above  downward  these  arches 


Fig.  80. — Sagittal  Section  of  the  Head  End  of  an  Embryo  Twelve  Days 
Old.  A,  alimentary  tube;  FB,  vesicle  of  the  forebrain  overriding  the  end  of 
the  alimentary  tube;  N,  neural  tube;  NC,  notochord;  OP,  oral  plate  (site  of 
future  mouth),  ■which  ruptures  during  the  fourth  week. 


overlap  and  partially  conceal  each  other ;  so  that  the  third  and  fourth, 
especially  the  fourth,  are  almost  entirely  concealed  by  the  first  and 
second.  The  uppermost  arch  appears  earliest.  The  appearance  of 
these  arches  is  the  first  indication  that  marks  the  commencement  of 
the  formation  of  the  face. 

Owing  to  the  progressive  growth  of  the  visceral  arches,  which 
causes  a  thickening  of  the  parts  that  immediately  adjoin  the  area 
already  mentioned  as  the  oral  plate,  and  on  account  of  the  presence 
of  the  prominent  overhanging  forebrain  vesicle  (neural  tube)  above, 
the  oral  plate  becomes  relatively  depressed,  and  we  have  thus,  in 
its  stead,  a  distinct  fossa,  which  is  called  the  oral  pit.    The  oral  pit 


164 


HEAD  AND  FACE. 


is  bounded  above  by  the  overhanging  forebrain  vesicle  and  below  and 
upon  the  sides  by  the  first  visceral  arches.  These  are  the  parts  which 
immediately  surround  the  oral  pit  and  which  are  finally  developed 
into  the  face;  the  oral  pit  represents  the  future  oral  and  nasal 
cavities. 

The  second,  third,  and  fourth  visceral  arches  are  not  concerned 
in  the  formation  of  the  face. 

The  next  change  noticed  in  the  parts  about  the  oral  pit  is  the 
appearance  of  a  thick,  rounded  mass  or  process  upon  the  upper  back 


Fig.  81.— Face  of  Embryo,  Fifth  W^'eek.  Front  view.  E,  eye;  IM,  inferior 
maxillary  process  (first  visceral  arch)  joins  in  middle  line  with  its  fellow  of 
the  opposite  side  to  form  the  mandibular  arch  (future  lower  jaw) ;  LN,  lateral 
nasal  process  (outer  extremity  of  the  frontal  process) ;  MN,  middle  nasal 
process  (middle  portion  of  frontal  process) ;  NN,  nasal  notch  (future  nostril) ; 
SM,  superior  maxillary  process  (upper  back  part  of  the  first  visceral  arch) ; 
1,  2,  3,  first,  second,  and  third  visceral  arches. 


part  of  the  first  visceral  arch  of  either  side;  this  is  called  the  superior 
maxillary  process.  Above,  corresponding  to  the  upper  margin  of  the 
oral  pit,  there  appears  a  single  broad  process,  which  is  developed  by 
the  forward  and  downward  growth  of  the  anterior  wall  of  the  vesicle 
of  the  forebrain;  this  is  called  the  frontal  process  or  frontal  plate, 
and  is  really  a  prolongation  of  the  front  wall  of  the  vesicle  of  the 
forebrain;  it  grows  downward  and  plays  a  very  important  role  in  the 
development  of  the  face.     At  this  stage  the  oral  pit  is  a  five-sided. 


CONGENITAL  DEFORMITIES  OF  THE  FACE. 


165 


deep  fossca,  bounded  above  by  the  frontal  process  or  frontal  plate,  below 
by  the  mandibular  arch  (inferior  maxillary  processes),  and  upon 
each  side  by  the  superior  maxillary  process. 

The  eyes  are  located  one  upon  either  side  of  the  head,  and  are 
bounded  below  by  the  upper  back  part  of  the  superior  maxillary 
process  and  internally  by  the  outer  border  of  the  frontal  process. 


Fig.  82. — Face  of  Embryo,  Fifth  Week.  Front  view.  The  anterior  portion 
of  the  visceral  arches  has  been  cut  away  to  show  the  interior  of  the  mouth 
cavity  (pharynx),  the  wall  of  which  shows  the  visceral  arches  with  interven- 
ing clefts  corresponding  to  those  upon  the  outside.  IM,  cut  surface  of  infe- 
rior maxillary  process;  LN,  lateral  nasal  process;  SM,  superior  maxillary 
process;  1,  2,  3,  4,  cut  surface  of  the  first,  second,  third,  and  fourth  visceral 
arches,  showing  the  corresponding  clefts  between  them.  Between  L2V  and 
middle  nasal  process  is  the  nasal  notch  (future  nostril). 


The  frontal  process,  frontal  plate,  is  broad,  and  consists  of  a 
middle  portion,  the  middle  nasal  process,  and  two  lateral  portions, — 
the  lateral  nasal  processes. 

The  middle  nasal  process  is  quite  broad,  and  its  lower  free  border 
is  deeply  notched  in  the  middle.  The  lateral  nasal  process,  one  on 
either  end  of  the  frontal  process,  is  separated  from  the  middle  nasal 


166 


HEAD  AND  FACE. 


process  by  a  deep  notch,  the  olfactor}'-  groove;  the  floor  of  each  olfac- 
tory groove  is  intimately  related  with  the  base  of  the  cerebral  vesicle, — 
organ  of  smell. 

During  the  fourth  week  the  plate  of  tissue  which  forms  the 
floor  of  the  oral  pit  becomes  very  thin,  consisting  only  of  the  epider- 
mic and  endodermic  layers.  It  is  called  the  "rachenhaut  of  Eemak,^^  or 
the  pharjTigeal  membrane,  and  during  this  week  ruptures  and  so 


Fig.  83. — Embryo   about  Fourth   Week,    seen   from    Side.     1, 
arches  with  clefts  between  them. 


2,    3,    4,   visceral 


establishes  a  communication  from  without  with  the  alimentary  tube, 
— pharynx. 

Somewhat  later,  about  the  fifth  week,  we  find  that  the  various 
processes  have  approached  each  other,  and  the  ajjpearance  begins  to 
suggest  the  ultimate  conformation  of  the  face.  The  superior  maxillary 
processes  are  nearer  the  middle  line,  the  whole  frontal  process  is 
longer,  and  its  separation  into  a  middle  and  two  lateral  portions 
is  still  more  pronounced  on  account  of  the  increased  depth  of  the 
olfactory  grooves.  The  eyes  are  fairly  well  bounded,  but  are  still 
located  upon  the  side  of  the  head. 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  167 

About  the  seventh  week  wo  note  that  the  superior  maxillary 
process,  in  part,  has  become  fused  with  the  lateral  nasal  process  of 
the  frontal  plate;  this  line  of  fusion  corresponds  to  the  position  of 
the  tear-duct.  If  union  does  not  occur  along  this  line,  we  have  a  so- 
called  orbito-nasal  or  oblique  facial  cleft.  The  eye  is  entirely  sur- 
rounded and  is  placed  more  to  the  front  of  the  face.  The  middle 
portion  of  the  frontal  plate,  the  middle  nasal  process,  is  still  notched 


Fig.  84.— Embryo  about  Eighth  Week.     Development  of  face  weU  advanced. 

in  the  center  and  broad ;  the  extremities  of  this  middle  nasal  process 
have  become  fused  with  the  lowest  and  most  internal  part  of  the 
superior  maxillary  process,  and  by  this  union  the  upper  lip  is  formed 
and  at  the  same  time  the  olfactory  grooves  are  bounded  below,  and 
are  thus  converted  into  round  openings :  the  nostrils.  If  the  supe- 
rior maxillary  process  and  middle  portion  of  the  frontal  plate,  middle 
nasal  process,  fail  to  unite,  we  have,  as  a  result,  a  cleft  in  the  lip, — 
harelip;  this  may  or  may  not  reach  into  the  opening  of  the  nostril: 
i.e.,  may  be  complete  or  incomplete  according  to  the  extent  to  which 
the  parts  have  failed  to  unite. 


168  HEAD  AND  FACE. 

The  lower  edge  of  the  superior  maxillary  process  becomes  par- 
tially united  with  the  upper  border  of  the  mandibular  process,  the 
inferior  maxillary  process,  which  has  also  become  thickened,  and  in 
this  way  the  size  of  the  mouth  is  much  diminished.  If  this  union 
falls  short  of  normal  we  have  a  characteristic  deformity :  macrostoma 
or  transverse  facial  cleft.  The  face,  as  a  whole,  is,  therefore,  at  this 
period  closed  in,  but  the  nostrils  are  still  far  apart,  the  nose  broad, 
and  perfectly  flat  and  directly  forward,  and  the  upper  lip  is  still 
notched  in  the  middle  line.  This  type  of  face  often  persists,  and 
we  then  have  a  peculiar  "pug  face.^' 

The  openings  for  the  external  auditory  meatus  are  seen  low  down 
upon  either  side  of  the  head. 

The  external  auditory  canal  is  the  remains  of  the  posterior  part 
of  the  first  visceral  cleft:  i.e.,  that  between  the  first  and  second 
arches.  The  margins  of  the  orifice  of  the  auditory  canal  later  become 
nodulated;  these  nodules  coalesce,  and  in  this  way  the  auricle  is 
formed.  The  Eustachian  tube  and  the  tympanum  are  the  remains 
of  the  corresponding  first  internal  cleft  (from  pharynx).  The  ear- 
drum represents  the  point  where  the  epiderm,  at  the  bottom  of  the 
outer  cleft,  and  the  endoderm,  at  the  bottom  of  the  inner  cleft,  have 
coalesced  with  each  other. 

At  the  end  of  the  second  month  the  eyes  are  located  toward 
the  front  of  the  face.  The  nose  is  still  broad  and  flat,  although  the 
nostrils  are  rather  closer  together.  The  upper  lip,  representing  the 
middle  portion,  middle  nasal  process,  of  the  frontal  plate,  is  still 
notched  in  the  middle  line.  The  cavity  of  the  mouth  is  fairly  well 
closed  in  by  the  upper  and  lower  lips. 

To  recapitulate :  The  first  visceral  arch  is  eventually,  developed 
into  the  inferior  maxillary  bone  and  the  adjoining  soft  parts,  includ- 
ing the  lower  lip  and  the  fioor  of  the  mouth,  and  assists  in  the  forma- 
tion of  the  tongue.  The  superior  maxillary  process  of  the  first  visceral 
arch  is  developed  into  the  superior  maxillary  bone  and  the  adjoining 
soft  parts,  including  the  hard  and  soft  palate.  The  frontal  plate, 
its  lateral  portion,  the  lateral  nasal  process,  forms  the  side  of  the 
nose,  including  the  nasal  bone;  its  middle  portion,  the  middle  nasal 
process,  forms  the  bridge  of  integument  between  the  nostrils,  reaching 
from  the  tip  of  the  nose  to  the  upper  lip,  and  the  cartilaginous  and 
bony  portions  of  the  nasal  septum  (vomer  and  perpendicular  plate 
of  the  ethmoid)  ;  also  the  middle  portion  of  the  upper  lip  and  inter- 
maxillary bone. 


CONGENITAL  DEFORMITIES  OF  THE  FACE. 


169 


The  intermaxillary  bone  was  first  described  by  the  poet  Goethe. 
It  is  a  small,  wedge-shaped,  bony  process  which  is  attached  to  the 
anterior  end  of  the  vomer  and  fits  into  a  corresponding  triangular 
space  in  the  anterior  part  of  the  hard  palate,  and  carries  the  four 
incisor  teeth.  The  line  of  union  between  this  bone  and  the  palatal 
processes  of  the  superior  maxillary  may  often  be  plainly  seen  in  the 


Fig.  85.— Face  of  Embryo  about  Eighth  Week.  The  various  processes  that 
go  to  make  up  the  face  have  coalesced,  but  the  embryonal  type  of  the  face  is 
still  well  marked.  Eyes  located  upon  the  side  of  face.  Ears  low  down.  Nose 
flat  and  projecting  forward,  with  nostrils  far  apart.  Upper  lip  still  notched 
in  the  middle. 


adult  upper  jaw-bone.  The  anterior  palatine  canal  marks  the  junction 
of  these  parts.  A  non-united,  abnormally  placed  intermaxillary  bone 
often  complicates  harelip. 

Formation  of  the  Palate. — The  superior  maxillary  process  of 
either  side  gives  off,  upon  its  inner  aspect,  a  shelf-like  process:  the 
palate  process.  These  processes  gradually  grow  toward  the  middle 
line  and  unite  with  each  other,  and  thus  form  the  hard  and  soft 


170  HEAD  AND  FACE. 

jDalate,  the  union  taking  place  from  before  backward,  the  uvula  being 
the  last  part  to  unite.  Union  between  the  palatal  processes  is  com- 
plete at  about  the  eleventh  week.  With  the  formation  of  the  hard 
and  soft  palate,  the  nasal  cavity  is  separated  from  the  oral,  or  mouth, 
cavity.  Failure  of  union  between  the  palatal  processes  gives  rise 
to  the  various  degrees  of  cleft  palate.  In  front,  where  the  two  halves 
of  the  hard  palate  join  with  the  intermaxillary  bone,  there  are  a 
suture  line  and  the  anterior  palatine  canal. 

The  vomer  and  the  perpendicular  plate  of  the  ethmoid  are  de- 
veloped from  the  middle  nasal  process  of  the  frontal  plate,  and 
divide  the  nasal  cavity  into  two  parts.  The  Junction  between  the 
lower  border  of  the  vomer  and  the  hard  palate  occurs  after  the  two 
palatal  processes  have  united  with  each  other  in  the  middle  line.  The 
nasal  cavity  opens  in  front  upon  the  face  through  the  nostrils  and 
behind  into  the  pharynx  through  the  posterior  nares. 

The  Teeth. — The  margins  of  the  upper  and  lower  jaw  become 
prominent,  and  in  this  way  form  the  alveolar  processes;  the  epithe- 
lium covering  these  processes  becomes  invaginated, — dips  dowi'  into 
the  substance  of  the  processes, — and  from  this  the  teeth  are  formed. 

The  floor  of  the  mouth  is  developed  from  the  first  visceral  arch. 

The  Tongue. — The  tongue  is  developed,  its  anterior  portion  from 
the  first  arch  and  its  posterior  portion  from  the  second  and  third 
arches.  The  anterior  part — the  body  and  tip — is  developed  from  a 
tubercle  which  appears  in  the  front  part  of  the  mouth  at  the  junction 
of  the  two  halves  of  the  first  arch.  The  back  part,  the  root,  is  devel- 
oped in  the  back  part  of  the  mouth  from  the  wall  of  the  pharynx, 
from  two  tubercles  at  the  junction  of  the  second  and  third  arches. 
These  two  parts  of  the  tongue,  the  anterior  and  the  posterior,  become 
joined,  the  line  of  union  being  indicated  by  the  V-shaped  row  of 
papillae  upon  the  dorsum  of  the  adult  tongue.  At  the  apex  of  the  V 
there  is  a  dimple,  the  foramen  c^cum,  which  indicates  the  point  of 
junction  of  the  parts  of  which  the  tongue  is  formed.  As  the  tongue 
is  developed,  it  increases  rapidly  in  size,  occupying  the  mouth  cavity 
and  projecting  up  into  the  future  nasal  cavity.  As  the  palatal 
processes  grow  inward  to  meet  each  other  in  the  middle  line,  how- 
ever, the  tongue  is  gradually  forced  down  into  the  mouth  cavity 
proper,  where  it  belongs.  The  thyro-giossal  duct,  which  leads  from 
the  thyroid  gland  into  the  foramen  caecum,  may  persist  in  the  form 
of  an  open  duct  or  as  a  cystic  enlargement  in  the  base  of  the  tongue, 
floor  of  the  mouth. 


CONGENITAL  DKFOinnTrKS  OF  THE  FACE. 


171 


Deformities  of  the  Face. — These  consist  of  abnormal  clefts  and 
atresias,  which  may  be  partial  or  complete. 

Clefts  are  due  to  entire  or  partial  absence  of  normal  union  be- 
tween the  original  embryonal  processes  by  whose  coalescence  the  face 
is  formed.  Atresias  are  caused,  on  the  other  hand,  by  excessive  union, 
beyond  the  normal,  between  these  processes,  and  as  a  result  we  get 
a  partial  or  complete  closure  of  the  facial  orifices:  mouth,  nostrils, 
and  eyes.  Still  further,  the  union  between  the  processes  may  occur 
to  its  normal  extent,  but  the  lines  of  union  may  remain  permanently 
marked  by  cicatricial  seams  or  irregular  tags  and  nodules. 


Fig.  86. — Diagram  of  Congenital  Facial  Clefts.  Shaded  portions  indicate 
the  location  of  the  different  congenital  fissures.  HL,  harelip;  IM,  inferior 
maxillary  process;  LN,  *,  lateral  nasal  process  of  frontal  plate;  LA^,  lateral 
nasal  cleft;  J/JN',  middle  nasal  process  of  frontal  plate;  OF,  oblique  facial 
cleft;  SM,  superior  maxillary  process;  TF,  transverse  facial  cleft;  *,  lower 
part  of  lateral  nasal  process  which  takes  part  in  the  formation  of  the  upper 
lip,  but  not  of  its  red  border;  the  free  red  margin  of  the  lip  is  formed  by  the 
union  of  the  lower  part  of  the  middle  nasal  process  (l/iV)  and  the  lower  part 
of  the  superior  maxillary  process  (SM). 

The  failure  of  the  embryonal  processes  properly  to  coalesce, 
with  the  resulting  clefts,  is  really  due  to  the  incomplete  development 
of  the  processes  themselves;  they  are  deficient:  i.e.,  too  small  to 
meet  each  other,  and  hence  the  clefts.  Tbe  clefts  vary  in  degree 
from  narrow,  incomplete  fissures  to  widely  gaping  spaces.  The  mar- 
gins of  the  clefts  may  be  smooth  or  they  may  be  irregular  and  marked 
by  nodular  processes,  tags,  etc. 


172  HEAD  AND  FACE. 

The  congenital  deformities  of  the  face  may  be  divided  into  two 
general  groups: — 

(A)  Those  in  which  the  frontal  plate  or  process  is  concerned. 
Under  this  heading  we  have : — 

1.  Lateral  clefts  of  the  upper  lip  and  the  alveolar  process;  clefts 
of  the  palate  may  also  be  conveniently  included  in  this  group. 

2.  Miedian  clefts  or  notches  of  the  upper  lip  and  deformities  of 
the  nose. 

3.  Notching  of  the  wing  of  the  nose. 

4.  Oblique  facial  fissures,  etc. 

(B)  Those  in  which  the  first  visceral  arch  is  involved.  In  this 
group  we  have : — 

1.  Transverse  facial  fissures. 

2.  Median  fissures  of  the  lower  lip,  lower  jaw,  and  tongue. 

3.  Deformities  of  the  lower  jaw. 

Deformities  in  which  the  Frontal  Plate  is  Concerned.  Lateiral 
Clepts  of  the  Upper  Lip  and  of  the  Alveolar  Process  and 
Cleft  Palate. — Clefts  of  the  upper  lip  and  alveolar  process  depend 
upon  imperfect  union  of  the  middle  portion,  middle  nasal  process, 
of  the  frontal  plate  with  the  corresponding  lower  portion  of  the  su- 
perior maxillary  processes:  to  failure  of  the  intermaxillary  bone  and 
its  accompanying  soft  parts  to  unite  with  the  adjoining  portion  of 
the  face.  These  clefts  are  always  lateral  and  may  be  present  on  one 
or  both  sides.  Clefts  of  the  palate  (hard  and  soft)  depend  upon 
non-union,  partial  or  complete,  of  the  palatal  process  of  the  superior 
maxillary  process  of  either  side  with  each  other.  These  clefts  are 
median  when  the  processes  of  both  sides  are  at  fault.  If  the  palatal 
process  of  one  side  only  is  involved,  the  fissure  will  be  present  upon 
the  corresponding  side  of  the  middle  line,  the  palatal  process  of  the 
other  side  being  joined  with  the  lower  border  of  the  vomer,  thus 
shutting  off  the  nasal  cavity,  on  that  side,  from  the  mouth. 

If  union  has  failed,  on  both  sides,  between  the  middle  process  of 
the  frontal  plate,  the  middle  nasal  process,  and  the  corresponding  part 
of  the  superior  maxillary  process  of  either  side  (double  harelip  and 
fissure  of  the  alveolar  process)  and  between  the  palatal  processes  of 
the  superior  maxillary  processes  of  either  side  (cleft  of  the  hard  and 
soft  palate),  we  have  the  most  extreme  variety  of  this  group  of  deformi- 
ties. There  are  found  all  degrees  of  this  variety  of  deformity  from 
this  exaggerated  form  down  to  a  mere  notching  of  the  upper  lip 
(incomplete  harelip)  or  bifurcation  of  the  uvula. 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  173 

Harelip. — This  condition  may  be  incomplete  or  complete. 

Incomplete  harelip  consists  in  a  vertical  notch  in  the  free  mar- 
gin of  the  upper  lip.  It  is  located  to  one  side  of  the  middle  line 
between  the  middle  segment  and  the  lateral  segment  of  the  lip.  It 
varies  in  depth  from  a  barely  noticeable  notch  to  a  deep  fissure  which 
may  extend  almost  through  the  entire  lip,  leaving  but  a  narrow 
bridge  of  integument  separating  the  angle  of  the  notch  from  the 
nostril. 

In  complete  harelip  the  fissure  extends  all  the  way  through  the 
upper  lip  into  the  nostril.     It  may  be  associated  with  cleft  of  the 


Fig.  87. — Double  Complete  Harelip. 

alveolar  process  and  with  cleft  palate.  The  nose  is  unusually  broad 
and  flattened,  the  wing  of  the  nose,  on  the  side  corresponding  to 
the  cleft,  being  carried  outward  away  from  the  middle  line.  These 
deformities  may  involve  one  or  both  sides.  If  double,  those  of  the 
two  sides  may  differ  from  each  other;  the  fissure  on  one  side  may 
be  complete,  that  of  the  other  side  incomplete,  or  those  of  both  sides 
may  be  complete.  They  may  be  associated  with  cleft  of  the  alveolar 
process  and  with  cleft  palate,  the  intermaxillary  bone  often  being 
small  and  misplaced  forward.  The  entire  middle  segment  of  the 
lip  may  be  absent,  together  with  the  intermaxillary  bone  and  the 
vomer.  In  this  case  the  upper  lip  shows  a  broad,  median  space,  which 
opens  into  the  nasal  cavity. 

Cleft  of  the  Alveolar  Process. — With  harelip,  as  already  men- 
tioned, there  may  also  be  present  a  cleft  of  the  alveolar  process,  and 


174  HEAD  AND  FACE. 

this  may  vary  from  a  narrow,  incomplete  fissure  to  a  broad,  open 
space;  it  may  be  nnilateral  or  double,  and  is  usually  associated  with 
cleft  palate.  If  there  is  no  cleft  of  the  hard  palate,  the  cleft  of  the 
alveolar  process  terminates  at  the  anterior  palatine  foramen :  the 
meeting  point  of  the  palatal  process  of  either  side  and  the  inter- 
maxillary bone.  If  the  cleft  in  the  alveolar  process  involves  both 
sides,  the  intermaxillary  bone,  which  is  continuous  with  the  front 
of  the  vomer,  may  be  placed  forward  in  advance  of  the  rest  of  the 
alveolar  process,  especially  if  cleft  palate  is  also  present;  so  that  it 
and  the  corresponding  portion  of  the  upper  lip  seem  to  be  suspended 


Fig.  88. — Harelip    with   Advanced    IntermaxiUary    Portion. 

from  the  point  of  the  nose.  In  this  case  the  lower  tegTimentary  part 
of  the  septum  of  the  nose  is  absent,  the  soft  parts  which  represent 
the  middle  part  of  the  lip  being  continued  directly  with  the  tip  of 
the  nose.  This  advancement  of  the  intermaxillary  bone  is  due  to  the 
unrestricted  forward  growth  of  the  vomer,  which  is  not  inhibited  as 
is  normally  the  case  when  it  is  joined  to  the  palatal  processes.  If 
the  cleft  is  confined  to  one  side  of  the  alveolar  process  and  the  hard 
palate,  the  intermaxillary  bone,  as  it  is  carried  forward  by  the  growth 
of  the  vomer,  is  apt  to  become  markedly  twisted  upon  its  long  axis, 
so  that  its  anterior  surface,  instead  of  being  directed  forward,  looks 
almost  directly  toward  the  normal  side  of  the  face,  presenting  its 
prominent  sharp  lateral  edge  anteriorly.  The  intermaxillary  seg- 
ment may  be  entirely  absent,  as  already  mentioned. 


CONGENITAL  DEFORMITIES  OF  THE  FACE. 


175 


Cleft  Palate. — ^The  presence  of  a  longitudinal  fissure  which  may 
involve  the  hard  or  soft  palate  or  both.  It  is  caused  by  a  failure 
of  the  palatal  processes  of  the  superior  maxillary  processes  to  meet 
in  the  middle  line  and  coalesce.  In  these  cases  the  base  of  the  skull 
may  be  unusually  broad  and  the  pterygoid  processes  unusually  far 
apart. 

Cleft  of  the  Hard  Palate. — This  may  be  unilateral  or  double. 
If  one-sided,  the  palatal  process  of  the  normal  side  is  seen  to  be 
imited  with  the  lower  border  of  the  vomer,  shutting  off  that  side  of 
the  nasal  cavity  from  the  mouth,  while  upon  the  affected  side  the 
palatal  process  is  deficient  and  falls  short  of  meeting  its  fellow  of 


Fig.  89.— Double  Cleft  Palate  with  Advanced  Intermaxillary  Portion  (IM)   Carry- 
ing the  Sockets  of  Two  Incisor  Teeth.   V,  vomer   (septum  of  the  nose). 


the  opposite  side,  and  there  is  thus  left  an  opening  which  leads  into 
the  corresponding  half  of  the  nasal  cavity.  In  double  cleft  palate 
both  palatal  processes  are  deficient,  and  the  lower  free  edge  of  the 
vomer  may  be  seen  between  the  separated  edges  of  the  cleft.  Usually 
the  lower  border  of  the  vomer  does  not  reach  low  enough  to  present 
itself  in  the  fissure  between  the  edges  of  the  cleft,  and  the  cleft  thus 
has  the  appearance  of  a  median  cleft  when  it  is,  in  reality,  a  bilateral, 
or  double,  cleft. 

At  times  we  may  find  the  palatal  processes  of  either  side  prop- 
erly united  with  each  other,  but  the  vomer  fails  to  grow  down  suffi- 
ciently far  to  articulate  with  them,  and  there  is  thus  left  a  space 
below  the  lower  border  of  the  vomer  through  which  the  two  sides  of 
the  nasal  cavity  communicate  with  each  other.  The  vomer  does  not 
play  any  part  in  the  formation  of  the  hard  palate. 


176  HEAD  AND  FACE. 

Cleft  of  the  hard  palate  ends  anteriorly,  either  at  the  anterior 
palatine  foramen,  which  marks  the  point  of  junction  between  the 
intermaxillary  bone  and  the  palatal  processes  of  the  superior  maxil- 
laries,  or  else  it  is  combined  with  a  single  or  double  cleft  of  the  alveolar 
process  and  harelip.  It  usually  ends,  posteriorly,  in  cleft  of  the  soft 
palate. 

In  cleft  palate,  especially  -if  double,  the  forward  growth  of  the 
vomer  is  unrestricted  on  account  of  its  not  being  joined  to  the  palatal 
processes,  and  by  this  forward  growth  the  intermaxillary  bone  and 
its  corresponding  soft  parts  may  be  carried  forward  beyond  the  line 
of  the  alveolar  processes,  the  intermaxillary  bone  often  being  bent 


Fig.  90. — Oblique   Facial    Cleft   Extending   into    the 
Temporo-frontal   Region. 

upward  or  twisted  upon  its  long  axis  (see  Fig.  89).  This  advance- 
ment of  these  parts  adds  very  much  to  the  difi&culty  of  correcting  the 
deformity. 

Cleft  of  the  Soft  Palate. — The  fissure  extends  from  the  tip  of 
the  uvula  for  a  varying  distance  into  the  soft  palate.  It  may  be  simply 
a  bifurcation  of  the  uvula,  but,  as  a  rule,  it  extends  all  the  way 
through  the  soft  palate  as  far  as  the  posterior  border  of  the  hard 
palate  or  for  some  distance  into  the  hard  palate.  It  may  be  com- 
bined with  a  lateral  or  double  cleft  of  the  hard  palate.  As  is  the 
case  with  cleft  of  the  hard  palate,  there  is  not  only  a  simple  lack 
of  union  between  the  two  halves  of  the  palate,  but  an  actual  defi- 
ciency of  tissue  which  prevents  the  parts  from  meeting  and  coalescing 
in  the  middle  line,  and  this  fact  is  important  in  considering  the 
operative  treatment  of  this  condition. 

With  the  exaggerated  forms  of  cleft  palate  there  is  frequently 
associated  imperfect  development  of  the  middle  nasal  process  of  the 


COXCiKNlTAL   DKFOU.MITIKS  OF  TlIK  FACK. 


177 


frontal  plate  or  it  may  be  entirely  absent:  tbe  intermaxillary  bone 
may  be  al)sont.  with  or  without  al)sence  of  the  vomer.  If  the  inter- 
maxillary bone,  etc.,  are  absent,  we  have  a  median  cleft  of  the  upper 
lip,  or,  better,  a  double  harelip  with  absence  of  its  middle  segment; 
and  this  condition  is  usually  associated  with  a  broad  cleft  in  the 
hard  and  soft  pa 'ate,  and  the  nose  may  be  soft  and  flattened,  on  ac- 
count of  the  absence  of  the  nasal  septum,  etc.  This  condition  is  apt 
to  be  accompanied  with  defective  cerebral  development. 

Mediax  Clefts  and  jSTotches  of  the  Upper  Lip. — These  de- 
formities depend  upon  exaggeration  and  persistence  of  the  embryonal 


Fig.  91.— Incomplete  Oblique  Facial  Cleft.  The  edge  of  the  upper  lip  is 
notched  and  a  cicatricial  line  extends  across  the  cheek  to  the  lower  eyelid, 
which  is  everted. 


notch  of  the  middle  portion,  the  middle  nasal  process,  of  the  frontal 
plate  and  failure  of  the  nostrils  to  approach  each  other.  These  de- 
fects are  much  less  frequent  than  the  preceding.  There  may  be 
simply  a  notch  or  fissure  in  the  middle  of  the  upper  lip  reaching  part 
way  through,  or  this  may  be  combined  with  a  grooving  or  furrow  upon 
ihe  point  and  dorsum  of  the  nose  and  a  wide  separation  between 
the  nostrils.  This  condition  may  be  so  pronounced  that  the  nose 
appears  to  consist  of  tw^o  halves  completely  separated  from  each 
other  and  each  containing  one  nostriL  Instead  of  this  extreme  de- 
gree of  deformity  the  nose  may  be  simply  flattened,  the  bridge  de- 
pressed, the  nostrils  far  apart  and  looking  directly  forward :  "dog 
nose."     The  fissure  in  the  upper  lip  instend  of  simply  notching  the 

12 


178 


HEAD  AND  FACE. 


lip  may  extend  completely  through  the  Avhole  lip  and  into  the  inter- 
maxillary bone.  This  variety  of  deformity  may  also  be  represented 
by  a  fistnla  of  the  tip  or  dorsum  of  the  nose. 

Lateral  Nasal  Clefts. — These  occur  with  or  without  harelip 
and  cleft  palate;  the  notch  or  fissure  involves  the  wing  of  the  nose. 
If  they  extend  upward  for  a  considerable  distance  through  the  side 
of  the  nosC;,  they  terminate  above,  not  in  the  inner  canthus,  but  to 
the  inner  side  of  the  inner  corner  of  the  eye;  they  represent  the 
embryonal  notch  between  the  middle  and  lateral  nasal  jDrocesses  of 


Fig.  92. — Transverse  Facial  Cleft. 


the  frontal  plate.  Fissures  of  the  side  of  the  nose,  that  resemble 
these,  but  terminate  above  in  the  inner  canthus  of  the  eye,  are  vari- 
eties of  oblique  facial  clefts. 

Oblique  Facial  Clefts. — Failure  of  normal  union  between  the 
lateral  process  of  the  frontal  plate  and  the  superior  maxillary  process 
of  the  first  visceral  arch.  They  correspond  to  the  embryonal  orbito- 
nasal line  of  coalescence.  These  deformities  may  be  very  extensive 
or  slight:  one-sided  or  double.  They  commence  below  at  the  edge 
of  the  upper  lip,  and,  after  splitting  this  at  the  usual  harelip  site, 
extend  upward  through  the  cheek,  alongside  of  the  wing  of  the  nose, 
not  into  the  nostril  like  harelip,  and  terminate  above,  at  the  lower 
margin  of  the  eye  (lower  lid)  or  inner  canthus.  They  may  extend 
beyond  the  orbit,  from  its  outer  corner,  upward  and  outward  into 
the  fronto-temporal  region  of  the  skull.     They  vary  from  a  narrow 


OPERATIONS  FOR  HAKELir,  CLEFT  RAEATE,  ETC.      179 

fissure  or  im'oin])letc  iiutcli  to  a  wide,  gaping  iissure,  Ijctweeii  the 
edges  of  which  is  tlie  eyeball.  This  class  of  deformity  is  frequently 
represented  in  its  simplest  form  by  a  notch  or  coloboma  of  the  lower 
or  upper  eyelid.  Instead  of  a  fissure,  this  deformity  may  be  repre- 
sented by  a  cicatrical,  nodulated  seam,  indicating  the  orbito-nasal 
junction. 

Deformities  in  which  the  First  Visceral  Arch  is  Concerned. 
Transverse  Facial  Clefts,  etc. — ^These  are  due  to  a  failure  of  tlie 
inferior  maxillary  process  of  the  first  visceral  arch  and  its  superior 
maxillary  process  to  coalesce  to  the  normal  extent.  This  deformity 
may  be  unilateral  or  double.  The  cleft  extends  from  the  corner 
of  the  mouth  outward  through  the  cheek  and  exposes  the  teeth : 
macrostoma.  If  the  reverse  of  this  process  occurs,  Ave  may  have  a 
mouth  so  small  as  to  require  surgical  interference :    microstoma. 

Median  Clefts  of  tite  Lower  Lip,  Lower  Jaw,  and  Tongue. 
— These  conditions  are  very  rare.  They  are  due  to  failure  of  the 
two  halves  of  the  first  visceral  arch  (mandibular  processes)  to  unite 
with  each  other  in  the  middle  line.  They  vary  from  a  slight  notch- 
ing of  the  lower  lip,  in  the  middle  line,  to  a  complete  separation 
through  the  lower  lip,  the  lower  jaw  at  the  symphysis,  and  the  tongue. 
The  tongue,  by  itself,  may  be  split  or  absent  or  bound  down  to  the 
floor  of  the  mouth  or  adherent  to  the  side  of  the  cheek,  etc. 

The  lower  jaw  may  be  imperfectly  developed,  rudimentary,  etc. 
It  may  be  split  in  the  middle  line  or  there  may  be  absence  of  the 
condyles,  etc.  As  the  formation  of  the  face  advances  the  jaw  is 
gradually  protruded  forward,  and,  if  arrested,  we  have,  as  a  result, 
the  receding  chin,  etc. 

OPERATIONS    FOR    HARELIP   AND    CLEFT  PALATE,    ETC. 

Operations  for  Harelip. — In  speaking  of  harelip — if  single — the 
flap  corresponding  to  the  angle  of  the  mouth  is  called  the  lateral 
flap,  or  segment,  and  the  other,  the  middle;  if  the  harelip  is  double, 
one  speaks  of  the  middle  segment  and  two  lateral  segments,  the  right 
and  the  left. 

Early  operation,  within  a  few  days  or  weeks  after  l)irth.  is 
desirable.  If  the  child  has  been  nursing  it  may  continue  to  nurse 
after  the  operation.  If  the  baby  is  bottle-fed  it  will  be  necessary 
to  feed  it  with  a  dropper  for  several  days  after  the  operation.  At 
the  time  of  tliG  operation  the  child  should  be  free  from  intestinal 
and  bronchial  trouble. 


180 


HEAD  AND  FACE. 


For  very  young  children,  a  few  days  to  a  few  weeks  old,  little 
or  no  angesthetic  is  necessary.  A  few  drops  of  chloroform  occasion- 
ally upon  the  Schimmelbusch  mask  will  suffice.  For  older  children 
more  complete  anaesthesia  is  desirable,  using  ether,  drop  by  drop,  upon 
the  mask  Avith  an  occasional  few  drops  of  chloroform. 

The  child  is  wrapped  in  a  blanket  in  such  a  way  that  the  arms 
and  legs  are  confined  and  then  held  upright  in  the  arms  of  a  nurse 
who  sits  opposite  the  operator.  The  child's  head  is  steadied  by  an 
assistant,  who  thrusts  the  head  a  little  forward  to  prevent  the  blood 
entering  the  mouth  during  the  operation.  It  may  be  more  convenient 
in  some  cases,  especially  older  children,  to  place  the  child  flat  upon 
the  back  with  the  shoulders  raised  high  upon  a  sandbag  and  the  head 
hanging  low  in  the  Eose  position. 


'■''^igSSiiiii 


Fig.  93.— Simple  Paring  of  the  Edges 
of  the  Notch  ^or  Incomplete  Hare- 
lip. 


Fig.  94.  —  Imperfect  Result  After 
Simple  Paring  and  Suture,  Showing 
the  Notch   Still   Present. 


The  instruments  that  are  required  consist  of  a  sharp,  narrow- 
bladed  knife  with  a  sharp  point,  several  tenacula,  mouse-tooth  forceps, 
and  narrow-bladed,  sharp-edged  scissors.  The  steps  of  the  operation 
consist  in  freshening  the  edges  of  the  cleft  and  suturing.  In  freshen- 
ing the  edges  one  should  cut  with  a  view  to  providing  broad,  raw 
surfaces  for  apposition;  they  should  be  cut  somewhat  obliquely,  and 
more  taken  away  from  the  skin  than  from  the  mucous  surface.  During 
this  step  of  the  operation  the  hemorrhage  may  be  controlled  by  an 
assistant,  who  compresses  either  segment  of  the  lip  between  the  finger 
and  thumb.  With  the  mouse-tooth  forceps  the  edge  of  the  defect  is 
seized  and  transfixed  with  a  knife,  and  the  incision  made  with  care  and 
deliberation.  In  order  to  bring  the  raw  surfaces  into  apposition  it 
may  be  necessary  to  liberate  the  flaps  by  cutting  them  free  from 
their  attachment  to  the  deeper  adjoining  parts :  from  the  alveolar 
process  and  the  anterior  surface  of  the  superior  maxilla. 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC. 


ISl 


After  the  edges  of  the  defect  have  been  pared,  the  flaps  cut.  etc., 
the  corresponding-  edges  of  tlie  flaps  are  brought  into  very  accurate 
apposition  with  a  sufficient  nund)er  of  silk  sutures.  A  number  of 
these  sutures  are  of  rather  lieavy  silk.  These  are  introduced  with 
a  fairly  large  straight  needle,  penetrating  deep  into  the  substance 
of  the   lip,   down  to,  but  not  through,   the  mucous   membrane   and 


'% 


Fig.  95. — Von  Graefe  Method  of  Paring 
an  Incomplete  Harelip  so  as  to  Increase 
the  Length  of  the  Raw  Apposed  Edges. 


Pig.  96.— Result     After     Suturini 


should  take  a  good  hold.  Between  these  sutures  the  skin  and  the 
mucous  membrane  on  the  inside  of  the  lip  are  brought  accurately 
together,  edge  to  edge,  with  a  number  of  superficial  sutures  of  finer 
silk.     No  dressings  whatever  are  applied. 


Fig.  97. — Nelaton    Operation    for    In- 
complete   Harelip.      Line    of    incision. 


Fig.  98. — Incision    Converted     into 
Perpendicular,   Ready  for   Suture. 


Operations  for  Incomplete  Harelip.  Simple  Freshenixg  of 
THE  Opposing  Edges  axd  Suture. — This  plan  would  not  answer 
even  for  incomplete  harelip,  since  a  notch  would  remain  which  would 
increase  with  time  as  the  scar  contracts,  especially  if  the  cleft  is  deep. 

Yon  Graefe  proposed  a  very  simple  method  to  increase  the  length 
of  the  apposed  edges  of  the  freshened  surfaces.  This  method  will 
answer,  however,  only  for  the  very  incomplete  defects,  and  not  for 


182 


HEAD  AND  FACE. 


wide  or  complete  s^Dlits.  It  consists  in  paring  the  edges  of  the  notch 
by  making  a  circular  incision,  which  arches  over  the  corner  of  the 
notch. 

NELATOisr  Method. — ^Without  removing  any  tissue,  an  incision 
is  made  through  the  substance  of  the  lip,  around  the  corner  of  the 
notch  and  parallel  with  its  edges,  and  after  converting  this  incision 


Fig.  99.— Result   After    Suture. 


Fig.  100. — Malgaigne  Operation  for 
Incomplete  Harelip.  Paring  and  for- 
mation  of   flaps. 


into   a   vertical   one   its   edges   are   united  with   several   interrupted 
stitches. 

Malgaigne  proposed  to  close  the  defect,  especially  where  the 
defect  is  considerable,  by  making  use  of  flaps  in  addition  to  fresh- 
ening the  edges.     In  his  operation  the  tissue  is  removed  from  the 


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Pig. 

102.— Result 

After 

Parts 

have 

been 

Sutured. 

Fig.  101.— Flaps  Turned  Down,  Ready 
for  Suture. 


angle  of  the  notch  only,  the  second  part  of  the  operation  consisting 
in  the  formation  of  two  flaps  by  simply  cutting  into  the  substance  of 
the  lip  along  either  side  of  the  defect,  commencing  near  the  angle 
and  cutting  toward  the  red  border  of  the  lip.  The  base  of  the  flap 
should  be  no  thicker  than  the  red  of  the  lip;  otherwise  it  is  very 
difiicult  to  turn  it  down.     The  tongues  of  tissue  thus  marked  out 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC. 


183 


are  turned  down  and  sutured  together,  with  the  result  that  the  cleft 
is  not  only  filled  in,  but  a  little  tongue  of  tissue  is  left  projecting 
beyond  the  free  line  of  the  lip  to  allow  for  future  retraction. 

The  objection  to  this  operation  is  that,  on  account  of  the  con- 
siderable torsion  to  which  the  flaps  are  subjected,  their  nourishment 
is  uncertain  and  they  may  become  gangi-enous,  especially  in  very  young 
and  poorly  nourished  children. 


'''''"^ri^^ii^ly 


Fig.  103.— Mirault  Operation  for  In- 
complete Harelip.  Paring  and  forma- 
tion of  one  flap. 


Fig.  104. — Parts    Ready    for   Suture. 


Mirault's  operation  is  an  improvement  on  Malgaigne's.  Only 
one  flap  is  made,  and  that  is  taken  from  the  edge  of  the  lateral 
segment.  The  flap  which  is  thus  formed  is  sutured  to  the  freshened 
edge  of  the  middle  segment.  This  single  flap  is  not  likely  to  become 
gangrenous  as  is  the  Malgaigne,  because  it  is  not  necessary  to  turn 


Fig.  105.— Result    After    Suture. 

it  down  so  far,  and,  secondly,  because  its  base  may  be  made  suffi- 
ciently broad  to  include  the  coronary  vessels.  In  forming  the  flap 
a  single  cut  is  made  into  the  substance  of  the  lip  proper,  striking 
well  above  the  red  margin  so  that  the  base  of  the  flap  corresponds 
to  the  lower  third  of  the  breadth  of  the  lip.  This  is  a  very  satis- 
factor^'  operation. 


18i 


HEAD  AND  FACE. 


Operations  for  Complete  Harelip. — Cases  in  which  the  split  ex- 
tends through  the  entire  width  of  tlie  lip  into  the  nostril. 

In  these  cases  it  is  not  onl}^  necessar}^  to  freshen  and  prepare 
the  edges  for  suture,  but  in  addition  it  will  be  necessar}^  to  separate 
the  flaps  from  their  bony  attachments,  alveolar  processes,  etc.,  in 
order  that  the  raw  surfaces  may  be  brought  together  and  sutured 
without  tension.  The  entire  width  of  the  lip  from  the  nasal  opening 
down  to  the  free  border  must  be  sutured  and  an  effort  made  to  correct 
the  nasal  deformity  at  the  same  time.  It  usually  suffices  to  separate 
the  outer  or  lateral  segment,  that  nearer  the  corner  of  the  mouth,  from 
its  attachment  to  the  superior  maxillary  bone.  Only  in  extreme  cases 
does  it  become  necessary  to  detach  the  other  flap  as  well.    To  separate 


''I' 9 


Fig.  106.— TFfZ?e;?sc7iWi7i  for  Complete 
Harelip.  Incision  carried  around  the 
al»  of  the  nose  in  order  to  liberate 
the  segments.  Formation  of  flaps  by 
incision  into   each   segment. 


Pig.  107. — Hagedorn  Operation  for 
Single  Complete  Harelip.  Lines  of 
incision. 


the  flap  from  the  underlying  bone  its  edge  is  seized  with  a  mouse- 
tooth  forceps,  and  drawn  inward  toward  the  middle  line,  and 
forward,  away  from  its  attachment  to  the  bone.  In  this  way  the 
fold  of  the  mucous  membrane  which  attaches  the  lip  to  the  gum  is 
put  upon  the  stretch,  and  may  be  incised  with  the  knife,  cutting 
toward  the  l)one  (superior  maxillary).  Further  separation  may  be 
accomplished  with  the  periosteum  elevator.  The  separation  is  car- 
ried sufficiently  far  and  deep  to  thoroughly  liberate  the  lateral  flap 
and  the  corresponding  side  of  tbe  nose  and  to  allow  of  the  parts  being 
readily  apposed  without  tension.  Hemorrhage  from  this  step  of  the 
operation  may  be  considerable,  especially  if  it  is  necessary  to  cut 
deep,  but  this  is  readily  controlled  by  a  few  minutes'  pressure  with 
the  fingers  and  a  gauze  pad.  Any  spurting  vessels  that  are  to  be 
seen  should  be  clamped  and  ligated  with  fine  catgut. 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE.   ETC. 


185 


Occasionally,  in  order  to  free  the  flap  sufficiently  it  may  be  neces- 
sary to  make  an  incision  around  the  wing  of  the  nose ;  this,  however, 
is  but  seldom  necessary  (Dieffenbach's  WellensclinUt).  The  Miranlt 
or  the  Hagedorn  operation  is  usually  done  for  this  condition  of  com- 
plete harelip.  The  ]\Iirault  is  quite  analogous  to  that  described  for 
incomplete  harelip.  The  entire  vermilion  edge  is  pared  away  from 
the  inner  segment  of  the  lip  and  a  flap  consisting  of  the  vermilion 
margin  of  the  lateral  segment  cut  and  turned  down.  The  results 
from  this  method  of  operating  are  very  satisfactory. 

Hacjedorn's  operation  consists  in  paring  away  the  edges  of  each 
flap,  first  from  the  margin  of  the  lateral  flap, — that  nearer  the  angle 
of  the   mouth, — ^and   then   from  the   margin   of   the   other   flap.      A 


Pig.  108.— Parts  Freshened  and  Ready 
for   Suture. 


Fig.  109.— Result    After    Suture. 


horizontal  incision  is  then  made  into  the  suljstance  of  the  lateral 
flap  and  an  oblique  one  into  the  median  flap.  With  a  scissors,  the 
long  strips  of  vermilion  border  which  have  been  pared  away  from 
the  edges  of  the  flaps  are  snipped  off.  When  the  parts  are  sutured 
there  is  left  a  little  process  hanging  from  the  edge  of  the  lip : 
this  retracts  in  time.  Before  suturing  the  flaps  they  must  be 
thoroughly  separated  from  their  bony  attachments. 

Operation  for  Single,  Complete  Harelip  Associated  with  Cleft  of 
the  Alveolar  Process  and  Advancement  of  the  Intermaxillary  Bone. 
— In  these  cases  the  intermaxillary  bone,  besides  being  misplaced, 
may  be  rotated  upon  its  long  axis  in  such  a  way  that  it  presents,  an- 
teriorly, a  prominent,  sharp  edge,  which  would  greatly  interfere  with 
the  healing  process.  Under  these  circumstances  it  becomes  necessary 
to  place  the  bone  in  its  natural  position.  It  is  forcibly  twisted  upon  its 
long  axis  and  pushed  back  into  place  so  that  its  sharp  lateral  edge 
will  not  project  under  the  suture  line  in  the  lip.    It  may  be  necessary 


186 


HEAD  AND  FACE. 


to  divide  the  process  from  its  attachment  to  the  alveolus  with  the 
hone-forceps  or  the  chisel  and  force  it  into  position  by  rotating  it 
partly  upon  its  long  axis.  After  the  intermaxillary  bone  has  been 
forced  back  into  position  the  defect  in  the  lip  may  be  closed  by  any 
of  the  methods  described  above. 

Operation  for  Double  Harelip  without  a  Prominent  Advanced 
Intermaxillary  Bone. — ^I'he  middle  segment  is  alv^ays  found  to  be  too 


Pig.  110. — Double  Mirault  Operation 
for  a  Double  Complete  Harelip. 
Paring  of  edges  of  defects. 


'.',''^1 
-—m.     :■-'■■ 


Fig.  111. — Flaps  Turned  Down  Ready 
for  Suture. 


short  to  take  part  in  the  formation  of  the  free  border  of  the  lip,  but 
it  may  be  used  to  form  the  middle  portion  of  the  lip.  From  the 
whole  of  the  middle  segment  the  mucous  membrane  edge  is  trimmed 
away,  and  a  Mirault  flap  then  made  from  the  edge  of  each  lateral 
segment.     If  the  nose  is  flattened  and  the  alse  spread  out,  this  de- 


Fig.  112.— Result   After    Suture. 

formity  may  be  corrected  by  separating  the  lateral  segments  of  the 
lips  and  the  sides  of  the  nose  from  their  deep  attachments — from  the 
superior  maxillary  bone.  The  fold  of  mucous  membrane  that  at- 
taches the  lateral  segment  to  the  alveolar  process,  etc.,  is  snipped 
with  the  knife  and  the  segment  of  the  lip  and  the  side  of  the  nose 
are  then  freely  separated  with  the  periosteum  elevator.  The  lateral 
segments  of  the  lip  must  be  very  loose.  Instead  of  the  Mirault,  a 
double  Hagedorn  may  be  done  for  this  condition. 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC. 


187 


Operation  for  Double  Harelip  with  Prominent  Advanced  Inter- 
maxillary Bone. — The  middle  segment  may  be  placed  very  far  for- 
ward upon  or  near  the  point  of  the  nose.  This  condition  may 
be  remedied  by  resecting  the  bony  part  of  the  prominent  inter- 
maxillary portion,  leaving  the  soft  parts  to  assist  in  making  the  lip. 
This  should  be  avoided,  however,  if  possible,  as  there  results  a  very 
unsightly  deformity;  the  lip  is  flat  and  has  a  sucked-in  appearance 


Pig.  113. — Hagedorn  Operation  for 
Complete  Double  Harelip.  Paring  and 
formation  of  flaps. 


Fig.  114. — Parts   Ready   for   Suture. 


and  lacks  the  support  of  the  corresponding  bony  part,  and  besides  the 
four  incisor  teeth  are  lost.  The  most  satisfactory  plan  is  to  forcibly 
separate  and  replace  the  intermaxillary  portion.  In  many  cases,  es- 
pecially very  young  children,  this  can  be  accomplished  by  forcible 
pressure  with  the  fingers.     Usually,  however,  it  will  be  necessary  to 


Fig.  115.— Result    After    Suture. 


separate  the  intermaxillar}-  portion  from  its  attachment  to  the  septum 
of  the  nose.  It  may  be  seized  with  the  bone-forceps  and  broken  away 
from  the  vomer,  or  the  line  of  fracture  may  extend  upward  and  back- 
ward through  the  vomer  proper.  The  segment  is  then  forced  back 
into  proper  position  and  the  edges  of  the  flaps  freshened  and  sutured. 
Blandin  recommends  the  resection  of  a  triangular-shaped  portion 
from  the  nasal  septum  posterior  to  the  intermaxillary  segment.  The 
base  of  the  triangular  piece  of  bone  which  is  thus  resected  corresponds 


188  HEAD  AND  FACE. 

in  Avidth  to  the  space  that  intervenes  between  the  middle  segment 
and  the  intermaxillary  notch,  its  apex  running  upward  into  the  sep- 
tum of  the  nose.  This  resection  may  be  very  conveniently  made  with 
a  pair  of  strong  bone  scissors.  The  apex  of  the  resected  triangular 
piece  should  be  directed  upward  and  forward,  toward  the  bridge  of 
the  nose,  in  order  to  avoid  cutting  the  anterior  palatine  vessels.  The 
intermaxillary  segment  may  then  be  readily  forced  back  into  proper 
position  and  tbe  cleft  closed.  If  the  anterior  naso-palatine  artery  is 
cut  in  removing  the  triangular  piece  of  bone,  the  hemorrhage  will  be 
severe.  Bardeleben  has  modified  the  alcove  procedure  in  that  he  first 
separates  the  periosteum,  ujDon  either  side  of  the  septum,  behind  the 
middle  segment,  and  then,  with  the  ordinary  strong,  straight  scissors, 
simply  cuts  through  the  septum  without  attempting  to  resect  a 
triangular  piece.  The  middle  segment  may  then  be  pushed  back  into 
place,  the  edges  of  the  divided  septum  sliding  past  one  another  and 
overlapping. 

It  will  be  necessary  to  liberate  the  lateral  segments  of  the  lip 
sufficiently  from  the  alveolar  processes  of  the  superior  maxillary  in 
order  to  bring  them  together  and  suture  them.  In  addition  to  de- 
taching the  fiaj^s  with  the  periosteum  elevator  it  may  be  necessary 
to  make  an  incision  upon  either  side  of  the  nose,  around  the  alee 
(Wellenschnitt  of  Dieffenbach)  before  they  are  sufficiently  loose. 
This  incision  should  be  avoided,  however,  if  possible. 

If  the  projecting  middle  segment  has  not  been  replaced  early, 
during  the  first  year  of  the  patient's  life,  the  problem  becomes  much 
more  difficult  because  later  the  segment  becomes  too  large  and  the 
corresponding  intermaxillary  space  too  small  to  accommodate  it. 
]\Iany  surgeons  make  it  a  rule  to  excise  the  advanced  intermaxillary 
bone  entirely.  This  is  undesirable  and  is  to  be  avoided  if  possible, 
as  the  support  of  the  lip  is  lost,  the  lip  has  a  flat,  sucked-in  appear- 
ance, and  the  four  incisor  teeth  are  lost;  but,  of  course,  a  dental 
bridge  and  artificial  teeth  can  be  fitted  to  substitute  for  these.  If 
the  intermaxillary  bone  is  replaced  it  usually  becomes  firmly  united 
to  the  adjacent  bon}^  parts  in  the  course  of  four  or  five  months.  It 
ma}^,  however,  remain  rudimentary  and  wabbly,  and  the  incisor  teeth 
may  be  crooked  and, imperfect.  If  a  considerable  part  of  the  septum 
of  the  nose  has  been  removed,  in  order  to  place  the  intermaxillary 
portion  in  its  normal  position,  the  point  of  the  nose  will  be  drawn 
down  so  close  to  the  front  of  the  face  as  to  give  it  a  peculiar  flattened, 
"bird-like"  appearance.     This  condition  improves  as  the  child  grows. 


OPERATIONS  FOR  HAREI.IR,  ClJiET   PALATE,  ETC.  189 

Operation  for  Cleft  Palate. — The  cleft  may  he  limited  to  the  soft 
or  hard  palate  or  may  extend  through  both. 

The  operation  upon  the  soft  palate  is  called  stapliylorrhaphy ; 
that  iipon  the  hard  palate,  uranoplasty.  Cleft  palate  is  frequently 
combined  Avitli  harelip.  This  latter  condition  may  be  remedied  dur- 
ing the  first  few  weeks  of  life,  leaving  the  cleft  in  the  palate  until 
later,  nntil  the  child  is  about  one  year  old.  The  cleft  in  the  palate 
diminishes  in  size  as  the  child  grows  if  the  harelip  has  been  cured. 
Eighteen  months  to  two  years  is  the  age  usually  selected  for  closing 
the  cleft  in  the  palate.  The  child  should  be  well  nourished,  weighing 
twenty-five  to  thirty  pounds,  free  from  bronchial  and  intestinal  dis- 


Fig.  116. — Whitehead  Gag  and  Tongue  Depressor  in  Place.     For  operations  upon 
the  hard  and  soft  palate. 

turbance.  Summer  is  the  preferable  time  for  operation.  Cleft  limited 
to  the  soft  palate  may  be  operated  upon  earlier, — ^before  one  year. 
The  operation  for  closure  of  a  complete  cleft  may  be  done-  in  two 
sittings :  closure  of  the  hard  palate  first  and  the  soft  palate  sub- 
sequently at  a  second  sitting.  As  a  rule,  however,  it  is  preferable 
to  close  the  entire  cleft  at  one  sitting. 

The  operation  is  best  done  with  the  child  lying  upon  the  back, 
the  shoulders  raised  high  upon  a  sandbag,  and  the  head  hanging  low 
in  the  Rose  position.  The  child  should  be  completely  anaesthetized 
(chloroform  with  ether)  administered  by  vapor  method  through  a 
bent  tube  introduced  into  the  mouth  or  Lumbard's  nasal  tubes  may 
be  used.  The  mouth  and  nasal  passages  are  thoroughly  cleansed 
with  saline  solution  before  commencing  the  operation.  The  jaws 
are  held  wide  open  with  a  Whitehead  gag.     In  some  cases  it  will  be 


190  HEAD  AND  FACE. 

found  more  convenient  to  remove  the  tongne  depressor  of  the  gag. 
At  times  it  is  difficult  to  adjust  the  tongue  depressor,  which  may 
press  the  tongue  hack  upon  the  glottis  and  interfere  with  hreathing. 
In  all  cases  a  strong  silk  suture  is  passed  through  the  tongue  so  that 
it  may,  at  all  times,  be  readily  pulled  forward.  Bleeding  during  the 
course  of  the  operation  is  controlled  by  pressure  with  hot  wipes  on 
long  sponge-holders,  and  the  operation  should  be  interrupted  at  short 
intervals  for  this  purpose.  TJsuall}^  the  hemorrhage  is  simply  an  oozing 
from  the  cut  edges.  By  carefully  minimizing  the  loss  of  blood  we 
are  enabled,  with  safety,  to  operate  upon  quite  5^oung  children — ' 
less  than  one  year  old.  The  throat  is  kept  clear  of  blood  with  small 
wipes  on  long,  slender  holders.  For  the  first  few  days  after  the 
operation  the  child  is  fed  with  a  dropper  or  it  may  continue  to  nurse. 
Staph YLOREBAPHY. — Closure  &f  a  split  in  the  soft  palate.  The 
first  step  of  the  operation  consists  in  freshening  the  edges  of  the  cleft. 
The  free  extremity  of  one  side  of  the  split  uvula  is  seized  with  a  long 
mouse-tooth  forceps,  and,  while  the  uvula  is  thus  held  taut,  it  is 
transfixed,  near  its  tip,  with  a  narrow-bladed,  sharp-pointed  knife, 
and  with  a  sawing  motion  a  thin  strip  is  cut  away  from  its  margin; 
the  edge  is  pared  along  the  entire  extent  of  the  split  from  the  tip 
of  the  uvula  to  the  posterior  border  of  the  hard  palate.  The  margin 
of  the  other  half  of  the  soft  palate  is  then  freshened  in  a  like  manner. 
Care  should  be  taken  to  freshen  the  angle  of  the  split.  The  strips 
should  be  so  cut  that  the  freshened  margins  present  a  beveled  edge, 
more  tissue  being  taken  away  from  the  buccal  than  from  the  nasal 
aspect  of  the  soft  palate,  so  as  to  give  us  broader  surfaces  for  suture. 
After  the  edges  have  been  freshened,  an  attempt  should  be  made  to 
appose  the  raw  edges  in  order  to  estimate  what  degree  of  tension,  if 
any,  exists.  It  is  absolutely  necessar}^  that  there  be  no  tension  what- 
ever. In  order  to  overcome  tension  of  the  soft  palate  it  may  be 
necessary  to  make  an  incision  in  the  soft  palate  upon  either  side. 
These  incisions  are  made  with  a  narrow-bladed  knife,  which  is  intro- 
duced just  to  the  inner  side  of  the  hamular  process.  This  process, 
which  is  located  behind  and  internal  to  the  last  molar  tooth,  is  very 
readily  felt.  These  incisions  pass  through  the  entire  thickness  of 
soft  palate,  from  behind  forward,  and  divide  the  tendons  of  the 
levator  and  tensor  palati  close  to  the  hamular  process,  where  they 
spread  out  into  the  soft  palate.  As  a  rule  it  will  not  be  necessary 
to  make  these  lateral  incisions,  especially  if  care  has  been  taken  to 
thoroughly  detach  the  soft  palate  from  the  posterior  border  of  the 


OrERATIOXS  FOR  HARELIP,  CLEFT  PALATE,  ETC. 


191 


hard  palate  and  also  from  the  adjoining  portion  of  the  pterygoid 
process,  which  corresponds  to  the  most  external  portion  of  the  posterior 
border  of  the  hard  palate.  If  this  separation  is  thorough,  the  two 
halves  of  the  soft  palate  hang  perfectly  loose  and  may  be  readily 
approximated  without  tension  and  the  liberating  incisions  can  be 
dispensed  with.  Even  when  the  cleft  is  limited  to  the  soft  palate, 
it  may  be  advantageous  to  raise  a  miico-periosteal  flap,  the  same  as 


Fig.  117.— Repair  of  Cleft  Palate.     Muco-periosteal  flaps  raised  and  edges  of  cleft 
in  hard  and  soft  palate  pared.    Sutures  all  introduced  and  ready  for  tying. 


when  closing  clefts  of  the  hard  palate;  so  that,  working  underneath 
this  flap,  close  to  the  surface,  of  the  bone,  we  may  be  able  to  completely 
separate  the  soft  palate  from  the  posterior  border  of  the  hard  palate. 
This  step  of  the  operation  is  accomplished  with  a  periosteum  elevator 
bent  near  the  end  to  almost  a  right  angle. 

To  unite  the  freshened  edges  of  the  soft  palate  a  small,  short, 
surgeon's  needle  with  a  moderate  curve  may  be  used.  The  needle 
is  carried  in  a  long  needle-holder,  and  as  it  pierces  the  tissues  its 
end  may  be  seized  with  an  artery  forceps  for  the  purpose  of  with- 


192  HEAD  AND  FACE. 

drawing  it.  A  combination  needle  and  holder  in  one  piece  is  pre- 
ferred by  many  surgeons.  The  stitches,  which  are  of  silk,  are  intro- 
duced from  before  backward  and  are  not  tied  until  they  have  all 
been  introduced.  From  four  to  five  sutures  are  required,  and  they 
should  be  placed  about  one-fourth  inch  apart.  The  edges  of  the  soft 
palate  should  be  accurately  apposed  without  tension  and  free  from 
hemorrhage. 

Uraxoplasty. — Closure  of  clefts  of  the  hard  palate.  The 
operation  of  Langenbeck  as  described  by  him  in  1862.  This  condition 
is  usually  associated  with  cleft  of  the  soft  palate,  in  which  case  both 
should  be  closed  at  the  same  time.  The  tip  of  one  side  of  the  uvula 
is  seized  with  a  long,  mouse-tooth  forceps  and  transfixed  as  described 
above.  The  paring  process  is  carried  forward  as  far  as  the  poste- 
rior border  of  the  hard  palate  and  then  continued  along  the  margin 
of  the  cleft  in  the  hard  palate,  close  to  its  edge,  cutting  through  the 
muco-periosteal  covering  down  to  the  surface  of  the  bone,  as  far  as 
the  anterior  limit  of  the  cleft.  Upon  the  other  side,  beginning,  again, 
behind,  near  the  tip  of  the  soft  palate,  the  margin  of  the  cleft  in 
the  soft  palate  and  in  the  hard  palate  is  freshened  in  a  similar  manner. 
During  this  step  of  the  operation  one  should  pause  occasionally  for 
a  few  minutes  and  apply  steady,  firm  pressure  with  a  hot  pad  in 
order  to  control  the  bleeding. 

The  next  step  of  the  operation  is  the  raising  of  a  muco-periosteal 
flap  from  the  surface  of  the  hard  palate  upon  either  side  of  the 
cleft.  An  incision,  corresponding  to  the  length  of  the  cleft,  is  made 
upon  the  surface  of  the  hard  palate  and  close  along  the  inner  margin 
of  the  alveolar  process.  This  incision  usually  extends  from  a  point 
anteriorly,  near  the  canine  or  first  premolar  tooth,  to  a  point  pos- 
teriori}', beyond  the  last  molar  tooth  into  the  commencement  of  the 
soft  j)alate.  If  the  incision  is  carried  thus  into  the  soft  palate  and 
the  flap  is  sufficiently  liberated  from  the  posterior  margin  of  the 
hard  palate,  as  described  below,  the  lateral  liberating  incisions  in 
the  soft  palate  may  usually  be  dispensed  with.  In  making  this  in- 
cision we  should  remember  the  point  where  the  posterior  palatine 
artery  emerges  from  the  canal  in  the  back  part  of  the  palate  and 
place  the  incision  fairly  close  to  the  alveolar  process  so  that  this 
vessel  may  be  left  in  the  flap  to  nourish  it  and  also  in  order  that 
we  may  avoid  the  hemorrhage  that  would  follow  its  division.  Many 
surgeons  claim  that  it  is  a  matter  of  indifference  whether  this  vessel 
is  cut  or  not,  as  the  flap  is  nourished  just  the  same  in  either  case 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC. 


193 


and  that  the  resulting  hemorrhage  is  readily  controlled  hy  pressure; 
nevertheless  one  should  try  to  avoid  dividing  it.  Into  this  incision 
a  sharp  periosteum  elevator  is  introduced, — it  nuiy  be  narrow  and 
rather  bent  near  the  end, — and  with  this  the  muco-periosteal  layer 
is  lifted  away  from  the  surface  of  the  bone  and  thus  made  very  freely 
movable  so  that  it  can  be  brought  over  to  meet  the  edges  of  the 
flap  on  the  opposite  side.     Care  should  be  exercised  to  separate  the 


Fig.  118.— Strips  of  Gauze  Passed  Around  the  Flaps. 


soft  palate  thoroughly  and  completely  from  the  whole  posterior  border 
of  the  hard  palate.  This  is  accomplished  by  working  close  to  the 
surface  of  the  l)one  with  a  periosteum  elevator  bent  upon  itself.  The 
mucous  membrane  upon  the  nasal  aspect  of  the  soft  palate  is  cut 
away  from  its  attachment  to  the  hard  palate  by  slipping  the  narrow- 
bladed  knife  or  the  scissors,  curved  on  the  flat,  under  the  flaps  and 
cutting  from  side  to  side  along  the  edge  of  the  hard  palate.  If  the 
detachment  of  the  soft  palate  has  been  thorough  the  two  halves  will 
hang  very  loose,  so  that  they  may  readily  l)e  l)rought  together  without 

13 


194 


HEAD  AND  FACE. 


tension.  Under  these  circumstances  there  will  be  no  necessity  for 
making  the  lateral  liberating  incisions  in  the  soft  palate. 

The  apposed  edges  of  the  c^eft  are  now  sutured  together,  com- 
mencing in  front,  behind  the  incisor  teeth,  and  working  backward, 
completing  the  operation  by  uniting  the  edges  of  the  soft  palate.  As 
already  mentioned,  the  sutures  are  not  tied  until  after  they  have 
all  been  placed.  Several  strips  of  plain  gauze  are  passed  around  the 
flaps  and  tied  and  then  twisted  so  that  the  knots  present  upward  into 
the  nasal  cavity.  These  serve  to  support  and  hold  the  flaps  together, 
stop  oozing,  and  serve  as  pack  for  the  lateral  incisions. 

Ordinarily  the  sutures  may  be  removed  after  ten  days.  The 
mouth  and  nose  should  be  irrigated  and  washed  out  frequently  both 
during  and  subsequent  to  the  operation.     The  original  defect  of  the 


Fig.  119. — Brophy's   Needle  for  Passing  Sutures. 


hard  palate  is  closed  ultimately  by  the  bone  which  is  produced  from 
the  periosteal  surface  of  the  flaps. 

Brophy's  Operation. — ^This  operation  is  adapted  to  very  young 
children, — within  a  few  weeks  of  birth.  In  older  children, — ^over 
three  months, — difiiculty  would  be  experienced  in  forcing  the  two 
halves  of  the  hard  palate  together.  The  most  desirable  time  is  within 
a  few  weeks  after  birth.  The  jaws  are  held  open  with  a  gag.  White- 
head or  Lane,  and  the  tongue  is  pulled  forward  with  a  ligature,  which 
is  passed  through  the  tip.  The  edges  of  the  cleft  in  the  hard  palate 
are  pared,  a  thin  strip  of  the  bone  margin  being  pared  away,  as  well 
as  the  mucous  membrane.  The  edges  of  the  cleft  in  the  soft  palate 
are  then  pared.  The  next  step  of  the  operation  consists  in  forcing 
the  two  halves  of  the  superior  maxilla  together  in  the  middle  line. 
A  loop  of  strong  silk  is  threaded  on  a  heavy  Brophy  needle.  The 
cheek  is  raised  and  the  needle  introduced  through  the  body  of  the 
maxilla  at  a  point  above  the  level  of  the  palatal  process  and  just 
behind  the  malar  process.  As  the  loop  of  silk  appears  in  the  cleft 
it  is  seized  with  a  forceps  and  the  needle  withdrawn.  At  a  correspond- 
ing point  on  the  other  side  of  the  superior  maxilla  the  needle  carrying 
another  strong;  silk  suture  is  affain  introduced,  and  this  suture  also 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC. 


195 


seized  as  it  appears  in  the  cleft  in  the  hard  palate.  The  nasal  septum 
is  perforated  with  the  needle  if  it  interferes  with  the  passage  of  either 
one  or  the  other  of  the  sutures.  The  end  of  the  first  suture  is  caught  in 
the  loop  of  the  second.  The  second  suture  is  then  witlidrawn  and  pulls 
the  end  of  the  first  with  it,  with  the  result  that  the  heavy  silk  suture 


F'ig.  120. — Brophy's  Operation.  Two  sutures  of  silver  wire  passed  across  the 
cleft  in  the  palate,  through  the  bodies  of  the  superior  maxillaries  and  iust  above 
the  level  of  the  alveolar  processes.  B,  germs  of  the  first  temporary  molar 
teeth. 


Fig.  121. — Brophy's  Operation.  The  sutures  drawn  tight,  and  cleft  closed. 
A,  line  of  fracture  between  the  body  of  the  superior  maxilla  and  the  alveolar 
process;   B,   germs  of  the   first  temporary   molar   teeth. 


passes  through  the  body  of  the  maxilla  from  side  to  side,  above  the 
level  of  the  palatal  processes  and  across  the  cleft  in  the  hard  palate. 
A  second  heavy  silk  suture  is  introduced  in  a  similar  manner,  an- 
teriorly, through  the  body  of  the  superior  maxilla.  The  silk  sutures 
are  used  to  draw  two  heavy   silver-wire   sutures  through  the  bone. 


196  HEAD  AND  FACE. 

from  side  to  side,  across  the  cleft.  The  silver-wire  sutures  are  carried 
through  the  holes  made  in  two  lead  plates,  which  are  ajDj^lied  against 
the  sides  of  the  jaw-bone  and  shaped  to  conform  to  the  buccal  surface 
of  the  bones.  As  the  wire  sutures  are  twisted  tight  the  two  halves  of 
the  maxilla  are  pressed  close  together  and  the  cleft  in  the  hard 
palate  thus  closed.  It  may  be  necessary  to  make  considerable  pres- 
sure with  the  thumbs  upon  the  two  halves  of  the  superior  maxilla 
before  one  succeeds  in  forcing  them  together.  In  some  cases  it  will 
be  necessary  to  incise  the  mucous  membrane  over  the  bone  and  divide 
the  bones  with  a  heav}^  knife  through  the  malar  processes  before 
they  can  be  forced  into  close  apposition.  The  bones  are  bent  or  frac- 
tured through  the  body  just  above  the  alveolar  processes.  The  edges 
of  the  soft  palate  which  have  been  freshened  are  united  with  a  suf- 
ficient number  of  silk  sutures.  The  plates  are  allowed  to  remain  two 
to  four  weeks.     The  harelip  is  repaired  at  a  subsecjuent  seance. 

OPERATIONS    UPON   THE    LIPS. 

Excision  of  the  Whole  Lower  Lip.- — This  operation  is  done  for 
malignant  disease.  At  times  the  angle  of  the  mouth  is  involved 
and  the  upper  lip  is  also  encroached  upon,  so  that  it  becomes  neces- 
sar}'',  in  addition  to  excising  the  lower  lip,  to  excise  a  triangular 
portion  of  the  upper  lip.  The  cutting  is  done  with  a  scissors,  and 
during  the  operation  the  bleeding  is  controlled  by  compression  with 
the  fingers.  If  the  jaw-bone  is  involved  in  the  disease  the  diseased 
portion  may  be  resected  with  the  chisel  or  saw,  but  a  bridge  of  bone 
sufficient  to  preserve  the  continuity  of  the  jaw  should  be  left  if  possible. 

Restoration  of  the  Lower  Lip  After  Excision  of  a  Wedge-shaped 
Portion. — After  the  whole  lower  lip  has  been  removed,  the  triangular- 
shaped  defect  that  remains  may,  in  many  cases,  be  remedied  by  sim- 
ply drawing  the  edges  of  the  wound  together.  The  edges  of  the 
wound  may  be  united  with  several  sutures  of  rather  heavier  silk 
which  go  through  the  entire  thickness  of  the  lip  down  to,  but  not 
including,  the  mucous  membrane,  and  these  may  be  j)laced  so  as 
to  control  the  hemorrhage  at  the  same  time.  There  are  then  applied 
additional  sutures  of  finer  silk  that  bring  the  edges  of  the  wound 
accurately  together.  As  a  result,  we  have  a  small,  rounded,  puckered 
opening,  representing  the  mouth,  which  is  formed  entirely  from  the 
upper  lip,  but  this  regains  an  appearance  very  much  like  normal, 
after  six  to  eight  months. 


OPERATIONS  UPON  THE  LIPS. 


197 


Formation  of  the  Lower  Lip  After  Complete  Excision.  Dieffen- 
bach-Jaesciie  Method. — To  remedy  a  triangular  defect  in  the  lower 
lip.  In  estimating  the  area  of  the  flaps  required  one  should  allow 
one-third  for  shrinkage. 

From  each  corner  of  the  mouth  an  incision  is  carried  outward 
and  somewhat  upward  into  the  cheek  for  a  sufficient  distance  to 
close  the  defect  in  the  lip,  allowing  one-third  for  shrinkage.  From 
the  end  of  each  of  these  incisions  a  second  curved  incision  is  then 
carried  downward  and  inward  toward  the  chin  so  as  to  terminate 
near  the  lower  border  of  the  jaw  and  under  the  angle  of  the  mouth. 
Stenson's  duct  should  l)e  avoided  in  making  these  flaps.    This  second 


Fig.  122. — Excision  of  Entire  Lower 
Lip,  with  Resulting  Triangular  De- 
fect. 


Fig.  123.— Triangular    Defect   in   Lower 
Lip   Closed   by   Suture. 


incision,  being  curved,  makes  the  flaps  more  movable.  The  mucous 
membrane,  corresponding  to  that  part  of  the  incision  that  reaches 
outward  from  the  corner  of  the  mouth,  should  be  cut  upon  a  higher 
level  than  the  skin  in  order  thus  to  obtain  a  mucous  membrane  flap 
which  is  sutured  over  the  edge  of  the  flap  to  the  edge  of  the  skin 
to  form  the  free  border  of  the  new  lower  lip.  For  the  rest  of  its 
extent  the  incision  goes  through  the  skin  and  mucous  membrane  upon 
the  same  level.  The  two  flaps  are  now  separated  from  the  lower  jaw, 
avoiding,  as  far  as  possible,  cutting  the  fold  of  mucous  membrane 
that  is  reflected  from  the  inner  surface  of  the  lips  to  the  gums. 
If  the  flaps  are  not  sufficiently  movable  to  bring  them  together,  the 
incisions  may  be  prolonged  downward  beyond  the  lower  border  of 
the  jaw  into  the  neck  and  the  flaps  loosened  still  farther  from  the 


198 


HEAD  AND  FACE. 


lower  jaw.  The  edges  of  the  flaps  are  then  united  with  interrupted 
silk  sutures  which  include  the  whole  thickness  of  the  lip  down  to, 
but  not  including,  the  mucous  membrane.  A  second  set  of  inter- 
mediate silk  sutures  brings  the  edges  of  the  skin  and  mucous  mem- 


Fig.  124. — Dieffenbach-Jaesche  Operation  for  Restoring  Lower  Lip.  Dotted 
lines  represent  the  edges  of  the  mucous  membrane,  which  is  cut  long  in  order 
to  cover  over  the  free  margin  of  the  new  lip.  The  edges  of  the  flaps  are 
drawn  together  and  the  mucous  membrane,  which  was  cut  long,  is  sewed 
over  the  free  edge  of  the  new  lip.  The  defect  upon  each  side  caused  by  the 
sliding  of  the  flaps  is  closed  by  suture. 

brane  into  accurate  apposition.  Corresponding  to  the  free  border  of 
the  new  lip,  the  edges  of  the  mucous  membrane  flaps,  which  were 
intentionall}^  cut  long,  are  sutured  to  the  skin.    Finally  the  semilunar 


Fig.  125. — Bruns  Method  of  Restoring 
the  Lower  Lip.  Dotted  lines  indicate 
that  the  mucous  membrane  is  cut  longer 
than  the  skin  in  order  to  provide  a 
mucous  membrane  border  to  the  new  lip. 


Fig.  126. — Flaps  Turned  Down  and 
Joined  to  Form  New  Lip.  Mucous  mem- 
brane is  suturd  over  the  free  margin  of 
the  new  lip.  The  defect  upon  each  side 
of  the  cheek  is  closed  by  suture. 


defects  upon  either  side  are  closed  with  sutures.     In  the  male  the 
scar  is  hidden  by  the  beard. 

Bruns  Method. — For  a  quadrangular  defect  of  the  lower  lip. 
A  square-cornered  flap  is  taken  from  either  side  of  the  face,  includ- 


OPERATIONS  UPON  THE  LIPS. 


199 


ing  the  whole  thickness  of  the  cheek,  and  these  are  turned  down 
into  the  defect  through  an  angle  of  ninety  degrees.  These  flaps  have 
a  good  blood-supply.  Avoid  Stenson's  duct.  The  apposed  edges  of 
the  flaps  are  united  and  the  mucous  membrane  sutured  to  the  edge 


Fig.  127.— Langenbeck  Method  of  Re- 
storing the  Lower  Lip.  An  oval  flap  is 
taken  from  the  region  of  the  chin. 


Fig.  128.— Oval  Flap  is  Raised  and  Su- 
tured into  Place  and  the  Defect  thus 
Closed. 


of  the  skin  to  form  the  free  margin  of  the  new  lip.  The  lateral 
defect  on  either  side  is  then  closed.  The  scars  that  result  are  upon 
the  cheek. 


Fig.  129.— Estlaender's  Method  of  Re- 
storing the  Lower  Lip  After  Partial 
Excision.  A  triangular  flap  is  taken 
from  the  upper  lip  and  cheek. 


Fig.  130.— The  Triangular  Flap  is 
Turned  down  and  Sutured  in  Place, 
thus  Closing  the  Defect. 


Laxgexbeck's  Method. — Formation  of  the  lower  lip  for  oval  de- 
fect. A  long,  rounded  flap  is  taken  from  the  region  of  the  chin  with 
its  base  directed  upward  and  outward.  Between  the  upper  border 
of  the  flap  which  is  thus  marked  out  and  the  lower  margin  of  the 
defect  there  is  a  triangular  tonorue  of  tissue.     This  tongue  of  tissue 


200 


HEAD  AND  FACE. 


is  partly  loosened  from  its  attachment  to  the  iinderl3dng  tissues. 
The  long  flap  is  raised  from  the  underlying  parts  and  shoved  upward, 
tilling  in  the  defect  in  the  lip,  and  the  triangular  tongue .  of  tissue 
is  brought  under  .it.    These  flaps  are  fixed  in  their  new  position  with 


.WO 


Fig.  131.— Dieffenbach  Wellenschnitt  for 
Restoration  of  the  Upper  Lip.  An  in- 
cision (WD)  is  carried  around  each,  side 
of  the  nose,  extending  through  the 
cheek. 


Fig.  132.— The  Flaps  are  Liberated 
from  the  Upper  Jaw-bone  and  are  Drawn 
Down  into  Place  and  Sutured.  The 
raw  space  upon  either  side  of  the  nose 
is   closed   with   suture. 


sutures.  The  whole  defect  may  be  closed  over  if  the  flaps  are  suf- 
ficiently detached.  The  great  disadvantage  of  this  method  is  that 
the  new  lip,  upon  its  free  edge  and  posterior  surface,  is  not  covered 
by  mucous  membrane,  and  shrinks  and  contracts  as  it  cicatrizes. 


Fig.  133. — Bruns  Method  of  Restoring 
Upper  Lip.  A  square  flap  taken  from 
either  cheek. 


Fig.  134. — Flaps  are  Turned  down  into 
Place  and  Sutured.  Defect  in  either 
cheek  is  closed  with  sutures. 


Estlaexder's  Method. — As  large  a  defect  as  that  left  after 
excision  of  three-fourths  of  the  lower  lip  may  be  covered  by  this 
method.  An  incision  is  made  reaching  from  the  comer  of  the  mouth 
upward,  through  the  whole  thickness  of  the  cheek,  to  the  level  of  the 


OPERATIONS   UPON  THE   LIPS.  201 

infra-orbital  foranieii  and  then  downward,  past  the  wing  of  the  nose, 
toward  the  pliiltrum,  to  a  point  close  to  the  carmine  border  of  the 
upper  lip.  If  the  coronary  branch  of  the  facial  artery  is  not  divided, 
the  flap  will  be  well  nourished.  The  flap  is  tlien  ti;rned  down  into 
the  defect  in  the  low^er  lip  through  an  angle  of  one  hundred  and 
seventy  degrees.  One  may  feel  the  pulsating  coronary  artery  before 
cutting  the  flap  and  should  positively  avoid  severing  it. 

The  resulting  deformity  is  bad,  the  mouth  one-sided,  the  corner 
of  the  mouth  corresponding  to  the  philtrum.  In  order  to  correct  this 
feature  a  subsequent  operation  might  be  done,  extending  the  corner 
of  the  mouth  outward,  but  it  would  be  necessary  to  wait  at  least  six 
weeks,  in  order  to  insure  a  good  blood-supply,  before  undertaking 
this  second  operation,  otherwise  there  would  be  danger  of  gangrene. 
Without  doubt  this  deformity  will,  in  time,  correct  itself  to  a  consider- 
able degree,  so  that  the  secondary  operation  may  not  be  necessary. 

Restoration  of  the  Upper  Lip. — Eestoration  of  the  upper  lip  is 
not  often  required,  as  this  part  is  but  rarely  the  seat  of  disease  that 
calls  for  its  excision. 

Estlaender's  Method  may  be  used  to  close  a  wedge-shaped  de- 
fect in  the  upper  lip,  the  flap  being  taken  from  the  lower  lip. 

Dieffenbach's  Wellenschnitt. — A  curved  incision  is  made 
through  the  whole  thickness  of  the  cheek  around  the  corner  of  the 
nose.  The  flaps  which  are  thus  marked  out  are  separated  from  the 
maxillffi  and  then  drawn  toward  the  middle  line  and  turned  down, 
so  that  the  raw'  edges  of  the  original  defect  become  the  free  border 
of  the  new  lip.  The  two  flaps  are  then  united  and  the  edges  of  the 
mucous  membrane  and  skin  sutured  together  along  the  free  margin 
of  the  new  lip.  The  mucous  membrane  corresponding  to  this  margin 
may  be  cut  a  little  longer  than  the  skin,  in  order  to  facilitate  the 
union  of  these  edges.  After  uniting  the  flaps  in  the  middle  line  the 
edges  of  the  defect  around  the  side  of  the  nose  may  be  brought  to- 
gether with  sutures. 

Small,  wedge-shaped  defects  may  be  closed  by  simple  suture,  if 
necessary,  combining  this  with  detachment  of  the  cheek  by  Dieffen- 
bach's WcUenschnitt. 

Brdxs  Method  may  also  be  used  to  restore  the  upper  lip  after 
its  complete  excision. 


PART  III. 

NECK  AND  TONGUE. 


SURGICAL  ANATOMY  OF  THE  NECK. 

The  neck  is  the  constricted  part  of  the  body  that  joins  the  head 
to  the  trunk.  The  spinal  column  passes  through  the  posterior  part 
of  the  neck,  inclosing  within  its  canal  the  spinal  cord.  The  anterior 
part  of  the  neck  is  made  up  of  important  organs  and  of  channels 
that  pass  between  the  head  and  the  trunk. 

The  Deep  Cervical  Fascia. — This  is  an  aponeurotic  layer  that 
serves  to  bind  the  structures  that  comprise  the  neck  into  a  com- 
pact, cylindrical  mass.  This  fascia  offers  a  strong  barrier  to  the 
extension  of  superficial  suppurative  processes  into  the  deeper  parts 
of  the  neck,  and  at  the  same  time  hinders,  to  a  considerable  degree, 
the  spontaneous  evacuation,  externally,  of  pus  which  is  located  deep 
in  the  neck. 

Anteriorly,  between  the  edges  of  the  sterno-mastoid  muscle,  the 
deep  cervical  fascia  covers  the  depressor  muscles  of  the  hyoid  bone — 
the  sterno-hyoid,  sterno-thyroid,  and  omo-hyoid.  Upon  the  side  of 
the  neck  it  is  found  beneath  the  sterno-mastoid,  and  may  be  traced 
from  the  posterior  border  of  this  muscle  backward  across  the  poste- 
rior triangle  of  the  neck  and  beneath  the  trapezius  muscle,  where 
it  serves  to  bind  the  long  muscles  of  the  neck  to  the  vertebral  column. 

Above,  the  deep  cervical  fascia  is  attached  to  the  lower  border 
of  the  jaw  and  to  the  back  of  the  skull,  and,  below,  to  the  upper 
border  of  the  sternum,  the  clavicle,  the  spine  of  the  scapula,  and 
the  spinous  process  of  the  seventh  cervical  vertebra:  vertebra  prom- 
inens.  In  the  middle  line  of  the  neck,  behind,  the  deep  cervical 
fascia  is  blended  with  the  ligamentum  nucha3,  which  is  prolonged 
deep  into  the  neck  to  be  attached  to  the  tips  of  the  spinous  processes 
of  the  cervical  vertebrse.  The  deep  cervical  fascia  is  firmly  attached 
to  the  body  and  horns  of  the  hyoid  bone. 

Anteriorly,  between  the  edges  of  the  sterno-mastoid  muscles,  the 
deep  cervical  fascia  covers  the  depressor  muscles  of  the  hyoid  bone, 
and  consists  of  two  layers,  the  anterior  of  Avhich  is  attached  to  the 
(202) 


SURGICAL  ANATOMY  OF  THE  NECK. 


203 


Fig.  135.— Section  through  the  Neck,  Level  of  Sixth  Cervical  Vertebra,  to 
Show  Arrangement  of  the  Deep  Cervical  Fascia  (Indicated  in  Red).  BP,  trunks 
of  brachial  plexus;  C,  complexus  muscle;  EJ,  external  jugular  vein;  E8, 
oesophagus;  LA,  levator  anguli  scapulee  muscle;  OH,  omo-hyoid  muscle;  P, 
platysma  muscle;  PV,  praevisceral  space;  RV,  retrovisceral  space;  S,  S''-,  splenius 
capitis  et  colli  muscle;  SA,  scalenus  anticus  muscle;  8C,  semispinalis  colli  mus- 
cle; SH,  sterno-hyoid  muscle;  SM,  scalenus  medius  muscle;  SS,  suprasternal 
space;  ST,  sterno-thyroid  muscle;  ST.M.,  sterno-mastoid  muscle;  SY,  sym- 
pathetic nerve;  TP,  trapezius  muscle;  TR,  trachea;  TY,  thyroid  gland;  V,  verte- 
bral artery  and  vein;  VAN,  internal  jugular  vein,  carotid  artery,  and  pneumo- 
gastric  nerve  inclosed  in  a  mass  of  loose  connective  tissue. 


204  XECK  AND  TONGUE. 

anterior  and  the  posterior  to  the  posterior  margin  of  tlie  upper  horder 
of  the  sternum.  Between  the  two  la^^ers  there  is  a  space  known  as 
the  suprasternal  space,  which  contains  some  fat,  lymphatic  tissue,  and 
a  venous  hranch,  the  anterior  jugular,  that  enters  the  external  jugular 
beneath  the  attachment  of  the  sterno-mastoid. 

The  suprasternal  space  extends  upward  almost  as  far  as  the 
h5^oid  bone  and  laterally  as  far  as  the  anterior  edge  of  the  sterno- 
mastoid  muscle. 

A  suppurative  process  in  this  space  is  pretty  effectively  shut  off 
from  the  deep  parts  of  the  neck  by  the  posterior  layer  of  the  deep 
cervical  fascia. 

In  the  front  part  of  the  neck,  below  the  level  of  the  hyoid  bone, 
the  pharynx  and  oesophagus  and  the  larynx  and  trachea  are  bound 
together  in  a  single  bundle  by  a  layer  of  fascia  that  completely  en- 
velops them;  the  thyroid  gland  is  also  included  within  this  sheath 
of  fascia  and  is  fixed  by  it  to  the  trachea,  xlnother  layer  of  fascia 
forms  a  sheath  for  the  muscles  that  are  contiguous  to  the  vertebral 
column :  anteriorly,  the  recti  and  longus  colli ;  laterally,  the  scaleni, 
cords  of  the  brachial  plexus,  and  the  levator  anguli  scapulae;  j)oste- 
riorly,  the  splenius,  complexus,  etc. 

Above  the  hyoid  bone  the  deep  cervical  fascia  reaches  from  the 
body  of  the  jaw-bone  to  the  hyoid  bone.  The  sul^maxillary  gland, 
surrounded  by  a  mass  of  loose  connective  tissue,  is  lodged  in  the 
submaxillary  triangle,  beneath   the  deep   cervical  fascia. 

Connective-Tissue  Spaces  Beneath  the  Deep  Cervical 
Fascia.  Prcevisceral  Space. — This  space  corresponds  to  a  mass  of 
loose  connective  tissue  that  is  situated  in  front  of  the  trachea  and 
thyroid  gland  and  beneath  the  deep  cervical  fascia  and  depressor 
muscles  of  the  hyoid  bone. 

If  an  opening  is  made  in  the  deep  fascia  and  a  probe  introduced 
into  this  sj)ace,  it  may  be  readily  forced  down  into  the  mediastinum, 
and  a  collection  of  pus  in  this  space  may  readily  gravitate  along  the 
same  route  into  the  mediastinum  with  fatal  results. 

Retrovisceral  Space. — This  is  the  recess  between  the  pharynx 
and  oesophagus  in  front  and  the  vertebral  column  Ijehind;  it  reaches 
from  the  base  of  the  skull  down  into  the  chest.  Pus  in  this  space 
may  readily  find  its  way  down  along  this  path  into  the  chest. 

Vascular  Space. — Upon  either  side  of  the  pharynx  and  oesoph- 
agus and  the  lar}aix  and  trachea  the  carotid  artery  and  its  adjoining 
structures   are'  found.      These   structures,  beside  the   carotid   artery. 


SURGICAL  ANATOMY  OF  THE  NECK.  2435 

consist  of  the  internal  jiiofiilar  vein  and  pneumogastric  nerve,  sym- 
pathetic nerve,  and  loop  formed  by  the  descendens  and  communicans 
noni.  These  structures  are  not  provided  with  a  distinct  sheath,  but 
are  lodged  in  a  mass  of  loose  connective  tissue,  which  may  be  traced 
all  the  way  down  into  the  thoracic  cavity. 

Suppuration  may  be  spread  along  the  course  of  these  structures, — 
for  example,  the  internal  jugular  vein. — and  thus  invade  the  chest 
cavity. 

The  Back  of  the  Neck. — This  region  of  the  neck  corresponds  to 
the  cervical  portion  of  the  trapezius  muscle.  It  is  limited  above  by 
the  occipital  prbtu1)erance  and  superior  curved  line  of  the  occipital 
bone,  below'  by  the  vertebra  prominens,  and  upon  the  sides  by  the 
edges  of  the  trapezius  muscle. 

The  skin  of  this  region  is  intimately  united  with  the  subcuta- 
neous connective  tissue,  which  is  very  dense  and  is  marked  by  hair- 
follicles  and  sebaceous  glands.  Infiammatoiy  processes  which  attack 
the  structures  of  the  skin  in  this  region  show  but  little  tendency 
to  spread  and  are  excessively  painful    (carbuncles). 

This  region  presents  two  longitudinal,  rounded  swellings — one 
on  either  side  of  the  middle  line — which  correspond  to  the  trapezius 
muscle.  Between  these,  in  the  middle  line,  is  a  depression  marked 
by  the  spinous  processes  of  the  cervical  vertebrae.  The  spinous  pro- 
cesses of  the  cervical  vertebrae  are  short  and  not  distinctly  felt,  ex- 
cept the  lower  ones:  that  of  the  seventh,  the  vertebra  prominens, 
is  especially  prominent.  They  are  joined  together  by  a  dense,  liga- 
mentous band, — the  ligamentum  nuchse, — which  is  continued  upward 
as  far  as  the  external  occipital  protuberance.  The  cervical  portion 
of  the  vertebral  canal  is  roomy  and  contains  the  spinal  cord.  This 
part  of  the  vertebral  column  lies  at  a  considerable  depth  from  the 
surface,  and  is  well  protected  by  the  overlying  muscles. 

The  Side  of  the  Neck. — This  region  is  quadrilateral ;  bounded 
above  by  the  lower  border  of  the  jaw-bone  and  an  imaginary  line 
drawn  from  the  angle  of  the  jaw  to  the  mastoid  process;  below,  by 
the  clavicle;  in  front,  by  the  middle  line  of  the  neck;  and,  behind, 
by  the  anterior  border  of  the  trapezius.  It  is  divided  into  two  tri- 
angles— an  anterior  and  a  posterior — by  the  sterno-nuistoid  muscle. 

The  stemo-mastoid  muscle  is  a  most  important  surgical  land- 
mark. It  is  attached  above  to  the  mastoid  process  and  the  adjacent 
part  of  the  occipital  bone;  below,  to  the  inner  end  of  the  clavicle 
and  the  upper  end  of  the  sternum.     This  muscle  not  only  divides 


206  NECK  AND  TONGUE. 

the  side  of  the  neck  into  an  anterior  and  a  posterior  triangle^  but^ 
being  a  broad  muscle  itself,  covers  important  structures  not  seen  in 
either  of  the  triangles;  therefore  in  addition  to  the  triangles  one 
might  well  describe  a  sterno-mastoid  region. 

The  side  of  the  neck  is  covered  by  the  skin,  beneath  which  the 
subcutaneous  fat  and  superficial  fascia  are  found,  and,  beneath  these, 
there  is  a  broad,  thin,  muscular  layer :  the  platysma.  This  muscle, 
which  is  spread  out  in  a  thin  sheat,  extends  from  the  lower  border 
of  the  inferior  maxilla  downward  and  backward,  being  continued 
downward  iDeyond  the  clavicle,  where  it  is  blended  with  the  subcu- 
taneous tissue  of  the  uj)per  part  of  the  chest.  The  platysma  is  inti- 
mately united  with  the  skin,  and  together  with  it  is  freely  movable 
upon  the  parts  which  lie  beneath  it  and  with  which  it  and  the  skin 
are  united  by  loose  connective  tissue.  It  will  be  observed  that  the 
platysma  does  not  cover  the  anterior  portion  of  the  neck  in  the 
lar}Tigeal  and  tracheal  regions. 

Beneath  the  sujDerficial  fascia  and  the  platysma — i.e.,  between  these 
and  the  deep  cervical  fascia — are  found  the  external  and  anterior 
jugular  veins  together  with  some  nervous  branches  which  are  derived 
from  the  cervical  plexus  and  from  the  facial. 

The  External  Jugular  Vein,  during  efforts  of  straining  and 
in  conditions  of  obstructed  venous  return,  may  become  distended 
and  sufficiently  prominent  to  be  recognized  beneath  the  skin.  This 
vessel  is  formed  above,  behind  the  angle  of  the  jaw,  by  the  junction 
of  the  posterior  auricular  vein  and  the  posterior  branch  of  the  tem- 
poro-maxillary  vein;  it  passes  straight  down  the  side  of  the  neck, 
crossing  the  sterno-mastoid  muscle  from  its  anterior  to  its  posterior 
border,  and,  below,  pierces  the  deep  cervical  fascia,  just  above  the 
clavicle  and  behind  the  attachment  of  the  sterno-mastoid  to  this 
bone,  to  empty  into  the  subclavian.  After  it  pierces  the  deep  cervical 
fascia  and  before  it  terminates  in  the  subclavian,  which  it  does  just 
external  to  the  tendon  of  the  scalenus  anticus,  it  receives  the  supra- 
scapular, transverse  cervical,  and  anterior  jugular  veins. 

The  Anterior  Jugular  Vein. — This  is  formed  in  the  hyoid 
region  by  the  junction  of  several  veins  from  the  upper  anterior  part 
of  the  neck,  and  passes  downward,  anterior  to  the  edge  of  the  sterno- 
mastoid  muscle,  between  the  superficial  fascia  and  platysma  and  the 
deep  cervical  fascia;  in  the  lower  part  of  the  neck  it  pierces  the 
anterior  layer  of  the  deep  cervical  fascia  in  front  of  the  sterno- 
mastoid  and  then  passes  backward,  beneath  this  muscle,  through  the 


SURGICAL  ANATOMY  OF  THE  NECK. 


207 


Fig.  136.— Side  of  the  Neck  to  Show  Triangles.  D.A.,  anterior  belly  of  the 
digastric;  D.P.,  posterior  belly  of  the  digastric;  E.J.,  external  jugular  vein; 
F.,  facial  vein;  E.G.,  hyo-glossus  muscle;  U.Y.,  hypoglossal  nerve;  I. J.,  inter- 
nal jugular  vein;  L.A.S.,  levator  anguli  scapulae  muscle;  M.H.,  mylo-hyoid 
muscle;  O.H.A.,  omo-hyoid  muscle,  anterior  belly;  O.H.P.,  omo-hyoid  muscle, 
posterior  belly;  P. A.,  posterior  auricular  vein;  P.J.,  posterior  jugular  vein; 
8. A.,  scalenus  pnticus  muscle;  8.C.,  subclavian  artery;  Sc.M.,  scalenus  medius 
muscle;  Sp.,  splenius  muscle;  St.H.,  sterno-hyoid  muscle;  St.M.,  sterno-mastoid 
muscle;  St.Ty.,  sterno-thyroid  muscle;  T.,  temporal  vein;  Tr.,  trapezius  muscle. 


208  NECK  AND  TONGUE. 

suprasternal  space,  to  join  the  external  jugular  just  before  this  vessel 
enters  the  subclavian.  The  external  and  anterior  jugular  veins  are 
often  cut  in  making  incisions  in  the  neck,  but  may  be  readily  clamped 
and  ligated  or  they  may  be  recognized  and  ligated  before  they  are  cut. 

The  Neeves  that  are  found  in  this  part  of  the  neck  beneath 
the  superficial  fascia  and  platysma  are  some  superficial  ascending 
and  descending  branches  of  the  cervical  plexus  and  descending  branches 
from  the  facial;  these,  however,  are  of  no  special  surgical  importance. 

The  Anterior  Triangle. — The  base  of  this  triangle  is  above, 
and  corresponds  to  the  lower  border  of  the  jaw  and  an  imaginary  line 
drawn  from  the  angle  of  the  jaw  to  the  mastoid  process.  Its  apex  is 
below  at  the  sterno-clavicular  articulation;  its  posterior  border  is 
formed  by  the  anterior  edge  of  the  sterno-mastoid  muscle,  and  its 
anterior  boundary  is  indicated  by  the  middle  line  of  the  neck. 

The  anterior  triangle  is  subdivided  into  an  upper  ^and  a  lower 
triangle  by  the  anterior  belly  of  the  omo-hyoid ;  this  is  a  thin,  double- 
bellied  muscle  that  swings  obliquely  across  the  side  of  the  neck,  being 
attached  above  to  the  hyoid  bone  and  below  and  behind  to  the  upper 
border  of  the  scapula.  The  lower  triangle  is  called  the  inferior 
carotid,  and  the  upper,  the  superior  carotid  triangle.  The  anterior 
triangle  presents,  in  its  upper  part,  a  third  triangular  space :  the 
submaxillary  triangle. 

The  Posterior  Triangle.- — This  is  the  reverse  of  the  anterior 
triangle.  Its  apex  is  above  at  the  mastoid  process;  its  base,  below, 
is  formed  by  the  clavicle;  its  anterior  border  corresponds  to  the 
posterior  edge  of  the  sterno-mastoid  muscle  and  its  posterior  border 
to  the  anterior  edge  of  the  trapezius.  The  posterior  triangle  is  sub- 
divided by  the  posterior  belly  of  the  omo-hyoid  into  two :  an  upper 
or  occipital  triangle,  and  a  lower  or  subclavian  triangle.  In  order 
to  demonstrate  these  triangles  it  is  necessary  to  draw  the  posterior 
belly  of  the  omo-hyoid  a  little  upward,  as  it  usually  lies  pretty  near 
the  clavicle,  being  fixed  in  this  position,  to  the  first  rib,  by  a  slip 
of  the  deep  cervical  fascia. 

Tpie  Sterno-Mastoid  Eegion. — Since  the  sterno-mastoid,  as  al- 
ready mentioned,  is  not  a  line,  but  a  muscle  of  considerable  breadth 
and  covers  structures  of  importance,  one  might  describe,  besides  the 
triangular  spaces  lying  in  front  of,  and  behind,  the  sterno-mastoid 
muscle,  a  "sterno-mastoid"  region,  and  we  will  proceed  to  do  this 
at  once  and  thus  dispose  of  it  and  then  consider  the  triangles  more 
in  detail.     The  sterno-mastoid  region  is  covered  by  the  skin  and  fat 


SURGICAL  AXATO.MV  OF  THE  NECK.  209 

(superficial  fascia)  and  to  a  considerable  extent  by  tbe  platysma. 
After  removing  these  layers  we  come  down  upon  the  surface  of  the 
muscle  covered  by  the  deep  portion  of  the  superficial  cervical  fascia. 
The  fibers  of  the  muscle  have  an  oblique  direction  from  above  down- 
ward and  forward,  and  it  is  crossed  from  above  downward  by  the 
external  jugidar  vein.  To  examine  the  structures  that  lie  beneath 
the  sterno-mastoid,  we  may  divide  the  muscle  through  its  middle  and 
reflect  eitlier  end.  Then,  after  cutting  through  the  deep  cervical 
fascia,  there  are  exposed  the  deep  muscles  which  lie  beneath  the  sterno- 
mastoid  and  which  are  connected  with  the  vertebral  column,  the  longus 
colli,  scaleni,  levator  anguli  scapula^  etc.,  the  cervical  plexus  of  nerves, 
the  carotid  vessels,  internal  jugular  vein,  etc.,  and  numerous  lym- 
I^hatic  glands. 

The  Inferior  Carotid  Triangle. — This  triangle  is  bounded 
in  front  by  the  middle  line  of  the  neck,  above,  and  behind  by  the 
anterior  belly  of  the  omo-hyoid,  below  and  behind  by  the  anterior 
border  of  the  sterno-mastoid. 

This  triangle  contains  the  larynx,  trachea,  thyroid  gland,  and 
oesophagus.  These  structures  are  partly  covered  over  and  concealed 
by  the  sterno-hyoid,  sterno-thyroid,  and  thyro-hyoid^  muscles. 

The  oesophagTis,  which  projects  Avell  beyond  the  left  border  of 
the  trachea,  is  more  accessible  in  the  left  triangle  than  in  the  right. 
Ascending  in  the  recess  between  the  trachea  and  the  oesophagus  is 
the  recurrent  laryngeal  neiTc;  this  nerve  enters  the  larynx  between 
the  thyroid  and  cricoid  cartilages,  behind  the  articulation  of  these 
two  cartilages.  Lying  to  the  outer  side  of  these  structures  (larAnx, 
trachea,  and  oesophagiis)  are  the  common  carotid  artery,  with  the 
internal  jugular  vein  upon  its  outer  side,  and  the  pneumogastric 
nerve  between  them,  but  on  a  plane  posterior.  The  middle  thyroid 
vein  passes  outward  across  this  space  to  enter  the  internal  jugular 
vein,  passing  across  the  front  of  the  common  carotid  artery  to  reach 
its  destination. 

In  this  triangle  the  common  carotid  artery  and  the  internal 
jugular  vein  lie  beneath  the  anterior  border  of  the  sterno-mastoid 
muscle,  which  is  the  guide  to  them  and  which  must  be  drawn  out- 
ward (backward)  in  order  to  expose  them.  Lying  still  deeper  in  this 
part  of  the  neck,  beneath  the  carotid  artery  and  the  internal  jugular 
vein,  are  the  inferior  thyroid  artery,  which  passes  inward  and  upward 
behind  these  vessels  to  reach  the  lower  part  of  the  thyroid  gland, 


^  The  thyro-hyoid  is  reaUy  the  continuation  of  the  sterno-thyroid. 

14 


210  NECK  AND  TONGUE. 

and  the  vertebral  artery,  which  enters  the  foramen  in  the  root  of 
the  transverse  process  of  the  sixth  cervical  vertebra.  The  sympa- 
thetic nerve  is  also  foimd  deep  in  this  space  behind  the  carotid  vessels, 
resting  npon  the  muscles  which  cover  the  front  of  the  vertebral 
column,  and  in  this  situation  it  presents  its  middle  cervical  ganglion. 

The  Superior  Carotid  Triangle. — This  space  is  bounded  be- 
hind by  the  anterior  border  of  the  sterno-mastoid,  above  and  in  front 
by  the  jjosteriof  belly  of  the  digastric  and  the  stylo-hyoid,  and  below 
and  in  front  by  the  anterior  belly  of  the  omo-hyoid.  The  floor 
of  this  space  is  formed  by  the  constrictor  muscles  of  the  pharynx 
and  the  thyro-hyoid  and  a  part  of  the  hyo-glossus  muscles.  It  con- 
tains the  upper  part  of  the  common  carotid  artery  and  its  bifurcation 
into  the  internal  and  external  carotids,  which  division  occurs  upon 
a  level  with  the  upper  border  of  the  thyroid  cartilage.  The  internal 
jugular  vein  lies  in  close  contact  with  the  outer  side  of  the  common 
carotid  artery  and  its  continuation,  the  internal  carotid;  and  the 
pneumogastric  nerve  still  holds  its  place  between  the  artery  and  vein, 
but  on  a  plane  posterior  to  both. 

The  vessels  in  this  triangle  are  superficial,  not  being  covered  by 
the  anterior  edge  of  the  sterno-mastoid,  but  lying  anterior  to  it.  The 
edge  of  the  muscle  is  here  also  the  guide  to  the  vessels.  A  chain  of 
lymphatic  nodes  is  located  along  the  front  border  of  the  sterno- 
mastoid  muscle,  and  some  of  them  are  in  very  close  proximity  to  the 
internal  jugular  vein. 

In  this  triangle,  the  external  carotid,  as  it  ascends  to  a  point 
behind  the  angle  of  the  jaw,  describes  a  slight  curve  with  the  con- 
vexity forward,  and  lies  rather  beneath  the  posterior  belly  of  the 
digastric  and  stylo-h5roid  and  upon  a  plane  anterior  to  the  internal 
carotid,  giving  off  several  important  branches :  among  them  the  su- 
perior thyroid,  which  passes  to  the  upper  part  of  the  thyroid  gland; 
the  lingual,  which  passes  forward  beneath  the  hyo-glossus  muscle  to 
supply  the  tongue;  and  the  facial,  which  passes  upward  and  outward 
over  the  lower  border  of  the  jaw.  The  occipital  and  the  posterior 
auricular  are  derived  from  the  posterior  aspect  of  the  external  carotid 
artery  and  ascend  in  a  direction  upward  and  backward. 

The  hypoglossal  nerve  arches  forward  across  the  external  carotid 
artery  upon  a  level  with  the  origin  of  the  occipital  artery. 

In  this  space  the  facial  vein  is  joined  by  a  large  branch  from 
the  temporo-maxillary,  and  then  passes  downward  and  outward  across 
the  external  carotid  and  internal  carotid  arteries  to  enter  the  internal 


SURCUCAL  ANATOMY  OF  THE  MECK.  o][X 

jugular  vein.  This  vein  is  often  cut  during  extirpation  of  glands 
in  this  triangle  and  gives  rise  to  a  copious  hemorrhage,  which  is 
readily  controlled  by  pressure  with  the  finger  in  the  wound  and  artery 
forceps.     It  nuiy  often  be  recognized  and  tied  double  before  it  is  cut. 

The  Subjviaxillary  Thiangle. — The  submaxillary  triangle  is 
bounded  above  by  the  lower  border  of  the  jaw  and  an  imaginary  line 
drawn  from  the  angle  of  the  jaw  to  the  tip  of  the  mastoid  process, 
below  and  in  front  by  the  anterior  belly  of  the  digastric  muscle,  and 
below  and  behind  by  the  posterior  belly  of  the  digastric  and  the  stylo- 
hyoid muscle.  The  apex  of  the  triangle  corresponds  to  the  attachment 
of  these  muscles  to  the  hyoid  bone.  When  the  coverings  of  this  tri- 
angle— consisting  of  the  skin,  subcutaneous  fat,  platysma,  and  deep 
fascia — are  reflected,  we  find  it  fairly  well  occupied  by  the  submaxil- 
lary gland,  which  rests  in  a  bed  of  loose  connective  tissue,  and  various 
lymph-nodes.  The  back  part  of  this  triangle  is  crossed  by  the  facial 
artery,  which  passes  upward  and  forward  over  the  upper  border  of 
the  submaxillary  gland  to  reach  the  lower  border  of  the  jaw,  over 
which  it  curves  on  to  the  side  of  the  face,  grooving  the  bone  just 
in  front  of  the  attachment  of  the  masseter  muscle.  The  facial  vein, 
which  lies  superficial  to  the  facial  artery,  after  receiving  the  suIj- 
mental  vein,  also  crosses  the  posterior  part  of  the  submaxillary  tri- 
angle, passing  downward  and  backward  across  (superficial  to)  the 
posterior  belly  of  the  digastric  and  stylo-hyoid  muscles  and,  after  unit- 
ing with  a  large  branch  from  the  temporo-maxillary  vein  in  the  upper 
part  of  the  superior  carotid  triangle,  enters  the  internal  jugular. 

After  the  submaxillary  gland  has  been  raised  out  of  its  bed,  its 
duct,  Wharton's,  may  be  seen  passing  forward  beneath  the  posterior 
edge  of  the  mylo-hyoid  muscle  to  open  anteriorly  in  the  floor  of  the 
mouth.  The  gland  may  be  isolated  and  cut  away  from  its  duct,  and 
then  the  floor  of  the  triangle  is  exposed  to  view.  The  floor  of  the 
triangle  is  formed,  for  the  most  part,  by  the  mylo-hyoid  muscle, 
whose  fibers  have  an  oblique  direction,  and  the  hyo-glossus,  which  lies 
upon  a  deeper  plane  than  the  mylo-hyoid  and  forms  the  posterior 
part  of  the  floor  of  the  triangle;  the  fibers  of  the  hyo-glossus  muscle 
run  straight  up  and  down  from  the  hyoid  bone  to  the  under  surface 
of  the  tongue.  The  lingual  artery  lies  beneath  the  hyo-glossus  muscle. 
The  submental  branch  of  the  facial  artery  passes  forward  parallel 
with  and  close  to  the  inner  surface  of  the  body  of  the  jaw,  resting 
upon  the  mylo-hyoid  muscle.  The  hypoglossal  nerve  may  be  seen 
passing  forward,  entering  the  submaxillary  triangle  from  beneath  the 


212  XECK  AND  TOXGUE. 

posterior  belly  of  the  digastric  muscle.  lu  the  triangle  this  nerve 
rests  upon  the  hyo-glossus  muscle,  disappearing  anteriorly  beneath 
the  posterior  border  of  the  mylo-hyoid  muscle.  Accompanying  the 
hypoglossal  nerve  is  the  lingual  vein,  which  glasses  backward  and 
enters  tlie  facial. 

The  hypoglossal  nerve  forms  the  base  of  a  second  smaller  tri- 
angle, which  corresponds  to  the  apex  of  the  submaxillary  triangle 
and  which  is  called  the  lingual  triangle. 

The  Lixgual  Triangle. — The  base  of  the  lingual  triangle, 
which  is  above,  is  formed  by  the  hypoglossal  nerve;  its  borders,  an- 
terior and  posterior,  by  the  respective  bellies  of  the  digastric.  The 
apex  of  the  triangle  is  located  below  where  this  muscle  is  attached 
to  the  hyoid  bone.  The  floor  of  the  triangle  is  formed  by  the  fibers 
of  the  hyo-glossus  muscle.  Directly  beneath  this  muscle,  in  the  space 
marked  out  as  the  lingtial  triangle,  the  lingual  artery  is  located,  and 
in  this  situation  it  is  very  readily  found  and  ligated.  The  hyo- 
glossus  muscle  is  picked  up  Avith  mouse-tooth  forceps  and  snipped 
through,  when  the  lirgual  artery  comes  into  plain  view  and  ma}"  be 
easily  surrounded  with  a  ligature  in  a  carrier.  The  lingual  artery 
is  ligated  preliminary  to  extirpation  of  the  tongue. 

The  Occipital  Triangle. — This  space  is  bounded  in  front  by 
the  posterior  border  of  the  sterno-mastoid,  behind  by  the  anterior 
border  of  the  trapezius,  and  below  by  the  posterior  bellj"  of  the  omo- 
hyoid. This  triangle  is  of  l3ut  little  surgical  importance.  It  is  cov- 
ered by  the  skin,  superficial  fascia  (fat),  by  the  platysma  in  part, 
and  iDy  the  deep  cervical  fascia.  Beneath  the  deep  cervical  fascia 
there  is  a  mass  of  loose  fat.  Lying  upon  the  deep  fascia  (superficial 
to  it)  is  the  posterior  jugular  vein,  which,  below,  at  the  posterior 
border  of  the  stemo-mastoid  muscle,  joins  the  external  jugular.  A 
chain  of  lymphatic  nodes,  which  lie  along  the  posterior  border  of 
the  sterno-mastoid  in  this  triangle,  are  frequently  diseased  and  re- 
quire removal.  The  space  is  crossed  by  the  superficial  descending 
branches  of  the  cervical  plexus.  The  spinal  accessory  nerve  emerges 
from  the  posterior  border  of  the  sterno-mastoid,  at  the  junction  of 
its  upper  .and  middle  thirds,  and  passes  obliquely  downward  and 
backward  across  this  space,  beneath  the  deep  cervical  fascia,  and  dis- 
appears under  the  anterior  border  of  the  trapezius  muscle,  which 
it  supplies.  The  floor  of  this  space  is  formed,  from  above  downward, 
by  the  splenius,  the  levator  anguli  scapulae,  and  the  middle  and 
posterior  scaleni. 


SIT{(JT('AL  ANATOMY  OK  TIIK  NKCK.  313 

The  Subclavian  Triangle. — This  triangle  corresponds  to  the 
lower  part  of  the  posterior  triangic.  It  is  covered  by  the  skin,  fat, 
and  superficial  fascia,  the  platysnia,  and  (k'c'|)  (HTvieal  fascia,  and  is 
crossed  by  the  superficial  descending  branches  of  the  cervical  plexus. 
In  the  front  part  of  this  space,  just  behind  the  posterior  border  of 
the  sterno-niastoid  muscle,  the  external  jugidar  vein  pierces  the  deep 
cervical  fascia.  After  the  integument,  etc.,  including  the  deep  cer- 
vical fascia,  have  been  incised,  the  boundaries  of  the  subclavian  tri- 
angle may  be  sought  for.  These  are,  below,  the  clavicle;  in  front,  the 
posterior  border  of  the  sterno-mastoid  muscle ;  and,  above,  the  poste- 
rior belly  of  the  onui-hyoid  ;  this  latter  muscle  lies  low  in  the  neck, 
close  to  the  clavicle,  and  in  order  to  demonstrate  the  triangle  it  may 
be  necessary  to  draw  it  somewhat  upward. 

Crossing  the  space  from  without  inward,  just  above  the  clavicle, 
are  the  transversalis  colli  and  suprascapular  veins;  these  form  a  plexus 
beneath  the  deep  cervical  Fascia  and  terminate  in  tlie  external  jugular; 
the  external  jugular  vein  enters  the  subclavian  just  external  to  the 
tendon  of  the  scalenus  anticus.  The  external  jugular  vein,  after 
piercing  the  deep  cervical  fascia  and  immediately  before  it  terminates 
in  the  subclavian,  also,  as  a  rule,  receives  the  anterior  jugular  vein. 
This  latter  drains  the  front  of  the  neck,  originating  above  in  the  hyoid 
and  suprahyoid  regions.  In  the  subclavian  triangle  there  is  also 
found  (beneath  the  deep  cervical  fascia)  a  mass  of  lymphatic  nodes, 
fat,  and  loose  connective  tissue  Avhich  communicates  with  the  lym- 
phatics of  the  breast  and  axilla  and  which  may  become  involved  in 
disease  of  the  breast.  The  tloor  of  the  su])clavian  triangle  is  formed 
by  the  scalenus  anticus  and  scalenus  medius  muscles.  In  order  to  ex- 
pose the  scalenus  anticus  muscle,  the  sterno-mastoid.  which  conceals 
it,  must  be  drawn  forward  (inward).  When  the  scalenus  anticus  is 
thus  exposed  the  phrenic  nerve  may  he  seen  passing  obliquely  down- 
ward and  inward  across  its  anterior  surface,  descending  into  the  chest 
across  the  front  of  the  first  part  of  the  subclavian  artery.  Beneath 
the  venous  plexus  above  mentioned,  and  lying  close  upon  the  muscles 
that  form  the  floor  of  the  triangle,  are  tlie  transversalis  colli  and 
suprascapular  arteries :  branches  from  the  first  part  of  the  subclavian. 
Emerging  from  lietween  the  scalenus  anticus  and  the  scalenus  medius 
and  passing  ob'icpicly  downward  and  outAvard  are  the  three  cords  of 
the  brachial  plexus.  Tln'y  disappear  beneath  the  clavicle  into  the 
axillary  space.  The  thii'd  part  of  the  subclavian  artery  is  found 
l)elow  the  cords  of  the  brachial  plexus,  deep  in  the  subclavian  triangle, 


214  NECK  AND  TONGUE. 

below  the  level  of  the  clavicle,  resting  in  the  groove  upon  the  upper 
surface  of  the  first  rib,  external  to  the  attachment  of  the  tendon  of 
the  scalenus  anticus.  The  tendon  of  the  scalenus  anticus  is  the 
guide  to  the  artery,  and  is  readily  recognized  in  the  inner  or  forward 
part  of  the  subclavian  triangle  as  a  tense  cord  and  may  be  followed 
do-wTiward  with  the  finger  as  far  as  its  attachment  to  the  first  rib. 
The  subclavian  vein  lies  some  distance  away  from  the  artery  in  front 
of,  and  internal  to  it,  the  artery  and  vein  being  separated  from  each 
other  hx  the  tendon  of  the  scalenus  anticus. 

As  the  subclavian  artery  emerges  from  the  chest  it  arches  out- 
ward and  forward  to  reach  the  first  rib.  That  portion  of  the  sub- 
clavian which  lies  behind  the  tendon  of  the  scalenus  anticus  is  the 
second  part  of  the  artery;  the  part  which  lies  to  the  inner  side  of 
this  tendon  is  the  first  part;  and  that  which  lies  external  to  the 
tendon  of  the  scalenus  anticus,  resting  upon  the  upper  surface  of 
the  first  rib,  is  the  third  part  of  the  artery :  the  part  that  is  usually 
ligated.  The  second  and  first  parts  of  the  subclavian  artery,  the  parts 
behind  and  internal  to  the  tendon  of  the  scalenus  anticus,  are  in 
direct  relation  with  the  dome  of  the  pleura  and  the  apex  of  the 
lung,  which  projects  upward  into  the  root  of  the  neck,  beneath  the 
scaleni  muscles,  for  a  distance  of  3  to  3%  cm.  above  the  level  of  the 
clavicle.  In  tying  the  third  part  of  the  subclavian  artery  one  should 
not  mistake  for  it  one  of  the  cords  of  the  brachial  plexus,  which 
lie  above.  The  artery  is  deep,  and  rests  directly  upon  the  first  rib. 
The  subclavian  vein  is  pretty  well  separated  from  the  artery,  lying 
in  front  of,  and  internal  to,  it  and  upon  a  rather  lower  level  than 
the  artery.  By  drawing  the  shoulder  down  we  depress  the  clavicle, 
and  may  thus  make  the  artery  more  accessible. 

The  Front  of  the  Neck. — This  part  of  the  neck  may  be  divided 
into  the  suprahyoid  region,  the  part  above  the  hyoid  bone,  and  the 
infrahyoid  region,  the  part  below  the  hyoid  bone.  The  infrahyoid 
region  presents  for  consideration  the  larynx,  trachea,  and  thyroid 
gland,  and  the  oesophagus,  which  lies  behind  these. 

The  IItoid  Bone. — ^This  is  a  horseshoe-  or  U-  shaped  bone, 
with  a  body  and  two  lateral  horns,  which  are  prolonged  backward, 
one  on  either  side,  and  two  lesser  horns,  directed  upward. 

In  the  natural  position  of  the  head  the  hyoid  bone  is  on  a  level 
with  the  lower  l^order  of  the  inferior  maxillary  bone,  and  is  not  dis- 
tinctly recognized  until  the  head  is  thrown  back.  It  is  not  station- 
ar}',  but  may  Ije  said  to  be  about  opposite  the  fourth  cervical  ver- 


SURGICAL  ANATOMY  OF  THE  NECK. 


215 


Fig.  137.— Front  of  the  Neck.  CC,  cricoid  cartilage;  DA,  anterior  belly  of 
digastric;  //,  hyoid  bone;  MH,  mylo-hyoid  muscle;  8H,  sterno-hyoid  muscle; 
8.TY,  sterno-thyroid  muscle;  TV,  thyroid  cartilage;  TR,  trachea;  TY.G, 
isthmus  of  thyroid  gland. 


216  NECK  AND  TONGUE. 

tebra.  To  it  are  attached  numerous  muscles,  coming  from  different 
directions.  To  the  upper  surface  of  its  body  is  attached  tlie  base  or 
root  of  the  tongaie;  from  its  lower  border  is  suspended  the  larynx. 
The  epiglottis  is  placed  behind  the  body  of  the  bone,  and  is  attached 
to  its  posterior  surface.  To  the  upper  surface  of  its  lateral  horn 
is  attached  the  middle  constrictor  of  the  pharynx,  and  it  thus  serves 
to  support  the  wall  of  the  pharynx  and  provide  a  fixed  point  for 
the  action  of  the  muscles  in  deglutition. 

SuPEAHYOiD  Region. — This  is  the  space  between  the  hyoid  bone 
and  the  lower  border  of  the  jaw.  This  region  is  covered  with  skin, 
superficial  fascia  (fat),  platysma,  and  deep  fascia;  the  deep  fascia  is 
attached  to  the  body  and  cornua  of  the  hyoid  bone.  Beneath  the 
platysma,  between  it  and  the  deep  fascia,  are  several  venous  branches 
which  go  to  form  the  anterior  jugular.  Upon  removal  of  the  deep 
fascia  a  triangular  space  is  exposed :  the  submental  triangle.  The 
apex  of  this  triangle  corresponds  to  the  symphysis  of  the  lower  jaw, 
its  sides  to  the  anterior  belly  of  either  digastric,  and  its  base  to  the 
hyoid  bone.  Its  floor  consists  of  the  mylo-hyoid  muscle,  with  its 
raphe  in  the  middle  line.  This  space  contains,  beneath  the  deep 
fascia,  several  lymphatic  nodes,  which  are  occasionally  the  seat  of 
disease  and  may  demand  extirpation.  Beneath  the  mylo-hyoid,  upon 
either  side,  in  the  floor  of  the  mouth,  the  sublingual  glands  are  lodged. 
The  floor  of  this  space  is,  at  times,  cut  through  in  operations  upon 
the  lower  jaw  and  in  order  to  reach  the  tongue.  A  distended,  per- 
sistent thyro-glossal  duct  or  an  accessory  or  detached  part  of  the 
thyroid  gland  may  be  present  in  this  space. 

Infrahyoid  ,Ee;gion. — ^This  is  the  region  below  the  hyoid  bone. 
The  skin  is  but  loosely  attached  to  the  underlying  structures;  be- 
neath the  skin  are  fat  and  the  deep  cervical  fascia.  The  platysma 
is  not  met  with  in  this  part  of  the  neck.  Below  the  hyoid  bone  may 
be  felt  the  thyroid  cartilage,  that  of  either  side  uniting  in  the  middle 
line  to  form  the  prominence  "Adam's  apple."  The  Adam's  apple 
is  not  prominent  in  the  female  or  child,  and  is  not,  therefore,  a  good 
surgical  guide.  Below  the  thyroid  the  cricoid  cartilage  may  be  felt. 
This  is  located  opposite  the  sixth  cervical  vertebra,  and  marks  the 
point  where  the  omo-hyoid  muscle  crosses  the  common  carotid  artery. 
The  cricoid  is  a  ring  of  cartilage  which  is  rather  narrow  anteriorly, 
but  of  considerable  breadth  posteriorly;  it  is  always  very  readily  felt, 
and  is  therefore  a  good  guide.  From  the  cricoid  down  to  the  upper 
border  of  the  sternum  the  space  is  occupied  by  the  trachea.     Just 


SrR(;i('AL  AXATOMY  OF  THE  NPXK.  217 

below  the  cricoid  cartilage  tlie  isthmus  of  tlie  thyroid  gland  lies 
transversely  across  the  front  of  the  tracliea,  each  lobe  of  the  gland 
extending  outward  and  upward  beneath  the  sterno-hvoid  and  sterno- 
thyroid uuiscles,  reaching  upward  upon  the  side  of  the  thyroid  carti- 
lage and  getting  into  close  proximity  to  the  common  carotid  artery  and 
its  adjoining  structures.  Between  the  cricoid  cartilage  and  the  isthmus 
of  the  tliyroid  gland  there  is  usually  a  space  about  one-half  inch  wide. 
On  either  side  of  the  middle  line,  passing  from  the  hyoid  bone  and 
thyroid  cartilage  down  to  the  sternum,  are  two  long,  flat,  ribbon-like 
muscles,  one  superimposed  upon  the  other :  the  stemo-hyoid  and 
sterno-thyroid.  The  sterno-thyroid  lies  beneath  the  stemo-hyoid, 
being  partly  concealed  by  the  latter.  The  sterno-thyroid  is  attached 
to  the  side  of  the  thyroid  cartilage  and  does  not  reach  the  hyoid  bone, 
but  is  continuous  with  the  short  tliyro-hyoid  muscle,  whicli  is  attached 
to  the  hyoid  bone.  The  inner  edges  of  these  muscles  do  not  meet  in 
the  middle  line  of  the  neck,  but  are  connected  with  each  other  through 
the  intervening  deep  cervical  fascia.  They  partly  cover  the  trachea 
and  sides  of  the  larvmx  and  the  lateral  lobes  of  the  thyroid  gland. 
Between  the  edges  of  the  muscles,  in  the  middle  line,  from  above  down- 
ward, and  covered  only  by  the  interposed  deep  fascia,  are  the  thyroid 
and  cricoid  cartilages,  the  isthmus  of  the  thyroid  gland,  and  the 
trachea. 

Between  the  hyoid  bone  and  the  upper  border  of  the  thyroid 
cartilage  there  is  a  space  which  is  filled  in  by  the  thyro-hyoid  mem- 
brane. This  membrane  is  pierced  on  either  side  Ijy  the  superior 
laryngeal  vessels  and  the  internal  laryngeal  branches  of  the  superior 
laryngeal  nerve.  This  membrane  may  be  cut  in  attempts  at  suicide: 
cut  throat.  Between  the  lower  border  of  the  thyroid  cartilage  and 
tlic  up]ier  border  of  the  cricoid  there  is  also  a  space  which  is  filled  in 
by  a  membrane:  the  crico-thyroid.  This  may  also  be  divided  in  cut 
throat.  Above  the  hyoid  bone,  running  transversely  inward  and  an- 
astomosing with  the  branch  of  the  opposite  side,  is  the  hyoid  branch 
of  the  lingual  artery.  Below  the  hyoid  bone  there  is  a  similar  trans- 
verse branch,  the  hyoid,  which  is  derived  from  the  superior  thyroid 
and  which  passes  likewise  inward,  anastomosing  across  the  middle 
line  with  its  fellow  of  the  opposite  side.  A  third  transverse  branch 
passes  inward,  above  the  cricoid  cartilage,  upon  the  membrane  between 
the  lower  border  of  the  thyroid  cartilage  and  upper  border  of  the 
cricoid  cartilage.  This  is  the  crico-thyroid  branch  of  the  superior 
thyroid  artery.     It  also  anastomoses  with  its  fellow  of  the  op])Osite 


218  NECK  AND  TONGUE. 

side.  Below  the  level  of  the  cricoid  cartilage  there  are  no  arterial 
Ijranche?  crossing  the  middle  line  except  through  the  isthmus  of  the 
thyroid  gland. 

The  cesoiDhagiis  lies  behind  the  trachea,  closely  applied  to  its 
posterior  wall,  and  when  empty  is  flattened  out  against  the  vertebras. 
It  projects  a  considerable  distance  to  the  left  of  the  trachea,  and  is 
therefore  easier  to  reach  through  an  incision  upon  the  left  side  of  the 
neck  than  upon  the  right.  Above,  the  oesophagus  is  continuous  with 
the  pharynx,  into  the  commencement  of  which  the  larvnx  opens,  the 
orifice  of  the  larynx  being  protected  by  the  overhanging  epiglottis, 
which  is  situated  below  and  behind  the  root  of  the  tongue.  The  poste- 
rior wall  of  the  larynx,  which  is  formed  by  the  broad  posterior  portion 
of  the  cricoid  carti].age,  is  in  close  relation  with  the  front  wall  of 
the  pharynx.  Only  a  thin  layer  of  connective  tissue  intervenes  between 
the  anterior  wall  of  the  pharynx,  which  consists  merely  of  a  layer  of 
mucous  membrane,  and  the  j^osterior  part  of  the  larjmx,  which  is 
made  up  chiefly  of  the  broad  posterior  part  of  the  cricoid  cartilage. 
When  the  pharynx  is  empty  it  is  flattened  out  against  the  vertebral 
column,  and  the  Jar^mx,  under  these  circumstances,  also  lies  close  to 
the  vertebral  column. 

From  the  cricoid  cartilage  down,  the  oesophagus  and  trachea, 
although  in  close  jDroximity  to  each  other,  form  two  distinct  tubes, 
which  may  be  readily  separated,  one  from  the  other.  The  posterior 
wall  of  the  trachea,  which  is  in  direct  relation  with  the  oesophagus, 
is  devoid  of  cartilaginous  bands,  and  therefore  a  foreign  body,  lodged 
in  the  oesophagus,  might  press  upon  this  contiguous,  non-cartilaginous 
portion  of  the  wall  of  the  trachea  and  cause  symptoms  of  strangula- 
tion. In  the  recess  between  the  trachea  and  oesophagus,  on  either  side, 
the  recurrent  larjTigeal  nerve  ascends  to  enter  the  lower  back  part  of 
the  larynx. 

The  Laryngeal  Eegion  is  covered  in  front  by  skin  and  deep 
fascia,  but  laterally  by  the  muscles,  the  sterno-hj^oid  and  sterno- 
thyroid and  thyro-hyoid,  and  by  the  lobes  of  the  thyroid  gland. 

The  interior  of  the  larynx  may  l^e  examined  after  splitting  the 
thyroid  cartilage,  taking  care  to  make  this  section  in  the  middle  line, 
between  the  anterior  attachments  of  the  vocal  cords.  The  true  and 
false  vocal  cords  are  then  exposed  to  view.  The  true  cords  are  the 
lower,  and  are  attached  anteriorly,  upon  either  side  of  the  middle 
line,  to  the  thyroid  cartilage,  midway  between  the  lowest  part  of  the 
incisura  in  its  upper  Ijorder  and  the  lower  border;  posteriorly  the 


SURGICAL  ANATOMY  OF  THE  NECK.  319 

true  vocal  cords  are  attached  to  the  arytenoid  cartilages,  Avliicli  rest, 
SMdvel-like,  upon  the  upper  surface  of  the  cricoid  cartilage. 

The  false  vocal  cords  are  tlie  loose  folds  of  mucous  meni])rane 
which  are  situated  above  the  true  cords,  inclosing  much  loose  con- 
nective tissue;  these  may  readily  become  (edematous — oedema  glottis 
— and  act  as  a  dangerous  obstruction  to  respiration. 

The  Thyroid  Gland. — The  istlunus  is  the  narrowest  part  of 
the  thyroid  gland.  It  joins  the  two  lobes  of  the  gland  across  the  mid- 
dle line,  resting  transversely  upon  the  upper  part  of  the  trachea. 
lAt  times  there  projects  from  the  upper  border  of  the  isthmus  a  pro- 
cess of  glandular  tissue,  the  so-called  middle  or  pyramidal  lobe,  which 
is  located  in  front  of  the  larynx  and  which  may  be  encountered  in 
operations  in  this  locality.  The  thyroid  gland  is  inclosed  in  a  distinct 
connective-tissue  capsule  which  will  be  found  considerably  thickened 
in  cases  where  pathological  processes  affect  the  gland.  Penetrating 
into  the  substance  of  the  gland  in  all  directions  are  connective -tissue 
processes  or  septa  which  are  given  off  from  the  capsule  and  which 
support  the  parynchyma  dividing  the  gland  into  lobes  and  lobules, 
and  in  which  the  lymphatics  course.  The  thyroid  gland  is  fixed  to 
the  cricoid  and  thyroid  cartilages  by  bands  of  connective  tissue.  These 
bands  connect  the  isthmus  of  the  gland  to  the  cricoid  cartilage  and  the 
lateral  lobes,  adjacent  to  the  isthmus,  to  the  sides  of  the  thyroid  carti- 
lage. It  is  necessary  to  divide  those  bands  that  connect  the  isthmus  to 
the  cricoid  cartilage  before  the  isthmus  can  be  dislocated  downward  in 
order  to  expose  the  upper  rings  of  the  trachea  in  performing  the 
operation  of  high  tracheotomy.  The  two  lobes  of  the  thyroid  gland, 
one  on  each  side,  are  prolonged  backward  and  upward  upon  the  sides 
of  tlie  trachea  and  larynx,  reaching  as  far  back  as  the  oesophagus 
and  thus  getting  into  close  relationship  wdth  the  common  carotid 
artery  and  its  adjacent  structures.  As  the  recurrent  laryngeal  nerve  of 
each  side  ascends  in  the  recess  between  the  trachea  and  oesophagus 
to  enter  the  lower,  posterior  part  of  the  larynx  it  lies  beneath  the 
corresponding  lateral  lobe  of  the  thyroid  gland  and  must  be  carefully 
avoided  in  operations  upon  the  thyroid  gland.  The  isthmus  of  the 
thyroid  lies  just  beneath  the  skin  and  deep  fascia,  whereas  the  lateral 
lobes  extend  upward  and  backward  underneath  the  sterno-hyoid  and 
sterno-thyroid  muscles. 

On  account  of  the  intimate  relationship  that  exists  between  the 
thyi'oid  gland  and  the  trachea,  tumors  involving  the  gland  ma}^  press 
upon  the  trachea,  greatly  narrow  its  lumen,  or  push  it  to  one  side. 


220  NECK  AND  TONGUE. 

If  tracheotoni}'  becomes  necessaiy  in  these  cases  it  may  be  difficult  to 
locate  the  trachea.  When  the  thyroid  is  enlarged  by  tumors,  etc.,  it 
may  be  seen  to  rise  and  fall  with  the  larynx  in  movements  of 
swallowing.  The  thyroid  is  supplied  by  the  superior  and  inferior 
thyroid  arteries  of  each  side,  and  drained  by  the  superior,  middle, 
and  inferior  thyroid  veins.  At  times  an  arterial  branch  from  the 
transverse  portion  of  the  arch  of  the  aorta  ascends  upon  the  front 
of  the  trachea  to  reach  the  lower  part  of  the  gland:  the  arteria  thy- 
roidea  ima.  The  arterial  and  venous  branches  form  a  network  upon 
the  surface  of  the  capsule  of  the  gland.  See  page  227  for  description 
of  the  superior  and  inferior  thyroid  arteries. 

The  Parathyroid  Bodies. — The  parathyroid  bodies  are  vari- 
able in  number,  usually  four,  occasionally  more.  They  are  small,  red- 
dish, glandular  structures  situated  in  the  connective-tissue  layer  that 
surrounds  the  thyroid  gland,  usually  posterior  to  the  gland  and  in 
more  or  less  c^ose  relationship  to  the  capsule  of  the  gland.  They 
are  6  to  7  mm.  long,  3  to  4  mm.  wide,  and  2.5  mm.  thick.  The 
parathyroid  bodies  are  not  constant  in  their  position.  Tavo  are  usually 
found  upon  the  posterior  asj)ect  of  the  oesophagus,  about  on  a  level' 
with  the  cricoid  cartilage,  and  closely  related  to  the  posterior  aspect 
of  the  corresponding  lobe  of  the  thyroid  gland.  The  lower  parathyroid 
bodies  are  situated,  as  a  rule,  in  close  relationship  to  the  lower  poles 
of  the  thyroid  gland  near  the  sides  of  the  trachea.  Tlie  parathyroid 
bodies  receive  their  blood-supply  chiefly  from  terminal  branches  of 
the  inferior  thyroid  artery.  Both  inferior  thyroid  arteries  should  not 
be  ligated  in  any  operation  upon  the  thyroid  gland.  It  is  essential 
that  the  parathyroid  bodies  be  not  injured  or  removed  in  operations 
upon  the  thyroid  gland;  nor  should  the  inferior  thyroid  arteries  of 
both  sides  be  ligated  in  any  operation  upon  the  thyroid  gland. 

The  function  of  the  parathyroid  bodies  is  not  clearly  understood, 
l)ut  it  is  certain  that  their  removal  results  in  tetany  that  inevitably 
terminates  fatally.  It  is  difficult  or  impossible  to  recognize  these 
bodies  during  the  course  of  operations  upon  the  thyroid  gland,  and 
therefore,  in  order  to  avoid  them,  the  posterior  portion  of  the  capsule 
behind  which  they  are  situated  must  be  left  undisturbed.  If  the 
parathyroids  have  been  removed  or  damaged  the  symptoms  of  tetany 
that  result  may  be  controlled  by  the  administration  of  the  nucleopro- 
teids  of  the  parathyroids  of  beeves  (Beebe). 

The  Suprasternal  Eegion  is  the  space  in  the  lower  front  part 
of  the  neck  al)ove  the, upper  border  of  the  sternum  and  limited  on 


SURGICAL  ANATOMY  OF  THE  .\KC'K.  231 

eitlier  side  by  the  anterior  border  of  the  sterno-mastoid.  The  sur- 
face shows  a  depression  here  known  as  the  suprasternal  fossa,  or 
fossa  ju^laris.  This  region  is  covered  by  the  skin,  beneath  which 
lies  the  deep  cervical  fascia,  which  splits  into  two  layers,  an  anterior 
and  a  posterior;  tliese  layers  are  attached  below  to  the  anterior  and 
l)osterior  edges  of  the  upper  border  of  the  sternum,  inclosing  a  space 
— the  suprasternal — between  them  which  is  occupied  by  some  con- 
nective tissue  and  lympathic  glands.  A  communicating  venous  branch 
which  connects  the  anterior  jugulars  of  either  side  is  also  included 
lietween  these  two  layers.  The  suprasternal  space  is  shut  off  from 
tlie  mediastinum  by  the  posterior  layer  of  the  deep  cervical  fascia, 
and  pus  in  this  space  is  thus  hindered  from  breaking  into  the 
mediastinum  and  is  more  apt  to  open  externally  througli  the  skin. 

Beneath  the  deep  fascia  lies  the  trachea,  its  anterior  surface 
being  readily  accessible  for  operation.  This  part  of  the  trachea  may 
I)e  lengthened  by  throwing  the  head  back.  If  the  trachea  is  incised 
transversely  the  wound  gapes,  and,  if  completely  severed  it  retracts 
into  the  chest  to  such  an  extent  that  it  may  be  difficult  or  impossible  to 
reunite  it.  At  times  the  arteria  thyroidea  ima  ascends  in  front  of 
this  lower  part  of  the  trachea  and  might  complicate  an  operation 
ujDon  this  part  of  the  tube. 

Descending  oljliquely  downward  and  outward,  from  the  lower 
part  of  the  thyroid  gland,  are  the  inferior  thyroid  veins.  These 
enter  the  right  and  left  innominate  veins  or  both  may  enter  the  left 
innominate,  within  the  chest,  behind  the  first  piece  of  the  sternum. 
The  inferior  thyroid  veins  are  large  and  lie  one  on  either  side  of 
the  middle  line.  As  they  descend  they  get  farther  away  from  the 
middle  line,  so  that  they  are  not  likely  to  Ije  encountered  in  the 
operation  of  low  tracheotomy  if  the  incision  is  kept  strictly  in  the 
median  line. 

The  Blood-vessels  of  the  Neck.  The  Common  Carotid  Artery. 
— This  vessel  ascends  in  the  neck  from  behind  the  sterno-clavicular 
articulation  to  the  level  of  the  upper  border  of  the  thyroid  cartilage, 
where  it  divides  into  the  external  and  internal  carotid.  The  course 
of  the  artery  is  indicated  by  a  line  drawn  from  the  sterno-clavicular 
articulation  to  a  point  midway  between  the  angle  of  the  jaw  and  the 
mastoid  process.  The  muscular  guide  to  the  artery  is  the  anterior 
border  of  the  sterno-mastoid. 

The  common  carotid  is  crossed  about  the  level  of  the  cricoid 
cartilage  by  the   omo-liyoid   muscle;  so  that  the  lower  part  of  the 


222  XECK  AND  TONGUE. 

arter}-  lies  in  the  inferior  carotid  triangle  and  the  ujDper  part  in  the  su- 
perior carotid  triangle.  The  arter}-  is  more  accessible  for  ligation  in 
the  upper  triangle.  In  the  lower  part  of  its  course,  below  the  omo- 
hyoid, the  arter}'  lies  beneath  the  anterior  edge  of  the  sterno-mastoid, 
whereas  above,  in  the  superior  carotid  triangle,  it  does  not  lie  beneath 
the  edge  of  the  sterno-mastoid,  but  rather  in  front  of  it,  and  is  here 
quite  superficial,  being  covered  onh^  by  the  integument,  platysma, 
and  deep  cervical  fascia.  Opposite  the  thyroid  cartilage  the  lateral 
lobe  of  the  thyroid  gland  comes  into  close  relation  with  the  artery, 
the  latter  grooving  the  gland.  In  its  course  up  the  neck  the  artery 
is  accompanied  by  the  internal  jugular  vein,  which  lies  close  upon 
its  outer  side,  and  by  the  pneumogastric  nerve,  which  lies  between 
the  vein  and  the  artery,  but  on  a  plane  posterior  to  both.  These 
structures  are  lodged  in  a  loose,  connective-tissue  bed,  which  is  con- 
tinuous below  with  the  connective  tissue  of  the  mediastinum. 

Upon  the  front  of  the  arter}',  opposite  the  middle  of  the  thy- 
roid cartilage,  the  descendens  and  communicans  noni  form  a  loop  from 
which  some  branches  are  given  off  to  supply  the  depressor  muscles  of 
the  hyoid  bone.  Posteriorly  the  SLxtery  rests  upon  the  transverse 
processes  of  the  lower  cervical  vertebrse  and  the  attachments  of  the 
vertebral  muscles.  The  sympathetic  nerve  lies  behind  the  artery 
and  is  closely  related  to  the  fascia  that  covers  the  jarevertebral  muscles. 
B'elow,  opposite  the  sixth  cervical  vertebra,  the  inferior  thyroid  arterv^, 
which  arises  from  the  first  part  of  the  subclavican,  curves  inward, 
behind  the  carotid,  etc.,  to  reach  the  lower  part  of  the  thyroid  gland. 
A  prominent  tubercle,  the  tubercle  of  Chassaignac,  marks  the  trans- 
verse process  of  ^  the  sixth  cervical  vertebra.  To  the  inner  side  of 
the  artery  are  the  trachea  and  oesophagus,  and,  higher  up,  the  larynx 
and  the  lower  part  of  the  pharynx.  The  larynx  projects  forward  be- 
tween the  arteries  of  either  side.  Ascending  between  the  trachea  and 
the  oesophagus  is  the  inferior,  recurrent,  laryngeal  nerve.  Opposite 
the  thyroid  cartilage  the  artery,  as  mentioned  above,  is  in  close  relation 
with  the  lateral  lobe  of  the  thyroid  gland.  Upon  the  outer  side  of 
the  artery  the  internal  jugular  vein  is  situated,  and  in  close  proximity 
to  the  vein  a  chain  of  lymphatic  nodes.  The  common  carotid  artery 
is  crossed  above  the  omo-hyoid  muscle  by  the  superior  thyroid  vein 
and  about  its  middle — i.e.,  below  the  omo-hyoid — by  the  middle 
thyroid  vein.  Both  these  veins  terminate  in  the  internal  jugular. 
Lower  in  the  neck  the  artery  is  crossed  by  the  anterior  jugular  vein, 
which,  as  a  rule,  terminates  in  the  external  jugular. 


SIROICAL  AXATO.MY  OF  THE  NECK.  223 

The  artery  is  covered  by  tlie  iiiteg'innent.  siipeiiic'ial  fascia, 
platysma,  and  deep  fascia.  The  lower  part  of  the  artery  lies  beneath 
the  sterno-niastoid,  and  this  muscle  must  therefore  be  drawn  aside 
in  order  to  expose  the  vessel.  Above,  upon  a  level  with  the  thyroid 
cartilage,  the  artery  lies  quite  superficial,  not  being  overlapped  by 
tlie  sterno-mastoid,  but  in  front  of  it,  and  here  its  pulsation  may  be 
l)oth  felt  and  seen. 

The  Internal  Carotid  is  continued  upward  in  the  same  course 
as  the  common  carotid,  lying  alongside  of  the  pharynx.  The  internal 
jugular  vein  lies  along  its  outer  side,  and  the  pneumogastric  nerve 
lies  beneath  both,  but  on  a  plane  posterior.  At  the  base  of  the  skull 
the  artery  enters  the  carotid  canal  in  the  petrous  portion  of  the 
temporal  bone,  and  after  traversing  this  canal  enters  the  cranium 
through  the  middle  lacerated  foramen.  In  the  neck  the  internal 
carotid  lies  in  the  superior  carotid  triangle,  covered  by  the  anterior 
edge  of  the  stemo-mastoid ;  it  is  situated  deeper  than  the  external 
carotid  and  upon,  a  plane  posterior  to  it.  The  stylo-glossus  and  stylo- 
pharyngeus  muscles,  as  they  pass  forward  to  the  tongue  and  to  the 
side  of  the  pharynx,  are  interposed  between  the  internal  and  external 
carotids.  Behind,  the  artery  rests  upon  the  transverse  processes  of 
the  upper  cervical  vertebrae  and  upon  the  rectus  capitis  anticus 
major  muscle.  The  sympathetic  nerve,  with  its  superior  ganglion, 
lies  behind  the  artery,  between  it  and  the  anterior  vertebral  muscles. 
Internally  the  artery  is  in  relation  with  the  side  of  the  phaiTUx.  The 
superior  laryngeal  nerve  descends  between  it  and  the  pharynx.  At 
its  origin  the  artery  lies  quite  superficial,  being  covered  by  the  in- 
tegument, platysma,  and  deep  fascia  and  overlapped  by  the  anterior 
margin  of  the  stemo-mastoid  muscle.  In  the  upper  part  of  its  course 
it  lies  deep  in  the  neck  beneath  the  posterior  belly  of  the  digastric 
and  stylo-hyoid  muscles  and  the  parotid  gland  and  the  stylo- 
pharyngeus  and  stylo-glossus  muscles,  these  two  latter  muscles  sep- 
arating it  from  the  external  carotid. 

At  the  base  of  the  skull  the  internal  jugular  vein  leaves  the  in- 
ternal carotid  artery  and  enters  the  skull  through  the  jugiilar  fora- 
men. This  foramen  is  located  external  and  posterior  to  the  opening 
which  marks  the  commencement  of  the  carotid  canal.  Just  below 
the  base  of  the  skull  the  glosso-pharyngeal  nerve  passes  forward  be- 
tween the  internal  jugular  vein  and  the  internal  carotid  artery  and 
then  continues  forward,  below  the  stylo-glossus  muscle,  to  reach  the 
side  of  the  base  of  the  tongue.     Just  above  the  level  of  the  hyoid 


224  NECK  AND  TONGUE. 

bone  the  h^'poglossal  nerve  curves  forward  between  the  arter}^  and 
the  vein.  The  spinal  accessory,  at  the  base  of  the  skull^  is  situated 
between  the  internal  carotid  arter}^  and  the  internal  jugular  vein, 
but  passes  backward  and  outward  to  reach  the  deep  surface  of  the 
sterno-mastoid  muscle. 

The  External  Caeotid  Arteey,  at  its  origin,  is  located  in  the 
superior  carotid  triangle  in  front  of  the  internal  carotid  artery.  It 
passes  upward  to  a  point  between  the  posterior  border  of  the  ramus 
of  the  jaw,  and  the  mastoid  process,  and  here,  within  the  substance  of 
the  parotid  gland,  divides  into  the  temporal  and  internal  maxillary. 
As  it  ascends  upon  the  side  of  the  neck  it  describes  a  gentle  curve 
Avith  the  convexity  forward  and  is  placed  upon  a  plane  anterior  to  the 
internal  carotid,  giving  off  many  branches  to  the  muscles  and  struct- 
ures in  the  neck  and  to  the  tongue.  It  lies  in  front  of  the  anterior- 
border  of  the  sterno-mastoid,  being  covered  only  by  the  skin,  platysma, 
and  deep  fascia;  higher  wp,  on  a  level  with  the  angle  of  the  lower  jaw, 
it  is  covered  by  the  posterior  belly  of  the  digastric  and  stylo-hyoid, 
and  at  its  bifurcation  into  its  terminal  branches  it  lies  deep  within 
the  substance  of  the  parotid  gland. 

The  external  carotid  artery  does  not  lie  as  deep  in  the  neck  as 
the  internal  carotid;  upon  a  level  with  the  angle  of  the  lower  jaw 
these  two  vessels  are  separated  from  each  other  by  the  stylo-glossus 
and  stylo-pharyngeus  muscles  (together  with  the  glosso-pharyngeal 
nerve).  Both  these  muscles  arise  from  the  styloid  process  and  pass 
forward,  between  the  external  and  internal  carotid  arteries,  in  their 
course  to  reach  the  side  of  the  tongue  and  the  pharynx. 

As  the  external  carotid  artery  lies  within  the  parotid  gland  it  is 
crossed,  upon  a  level  with  the  lower  border  of  the  lobe  of  the  ear,  hj 
the  divisions  of  the  facial  nerve.  The  temporo-maxillary  vein,  which 
is  formed  by  the  junction  of  the  temporal  and  internal  maxillary  veins, 
also  lies  superficial  to  it.  Below  the  angle  of  the  jaw  the  artery  is 
crossed  by  the  temporo-f acial  vein ;  this  vessel  is  formed  by  the  facial 
and  a  large  branch  from  the  temporo-maxillary,  and  after  receiving 
the  lingual  and  sometimes  the  superior  thyroid,  terminates  in  the 
internal  jugular. 

Below  the  level  of  the  hyoid  bone  the  external  carotid  gives  off 
the  superior  thyroid.  This  branch  passes  forward  and  downward  to 
the  lateral  lobe  of  the  thyroid  gland  and  gives  branches  to*  the  larynx. 
The  next  branch  given  off'  above  the  superior  thyroid  is  the  lingual. 
This    vessel   passes   forward,   beneath   the   digastric    and    st3do-h5roid 


SURGICAL  ANATOMY  OF  THE  NECK.  225 

muscles  and  beneath  the  hyo-glossus,  to  supply  the  tongue.  The 
next  branch  above  is  the  facial.  The  facial  is  directed  forward  and 
upward  and  curving  over  the  inferior  border  of  the  lower  jaw,  in 
the  groove  just  in  front  of  the  masseter  muscle,  ascends  upon  the  side 
of  the  face,  nose,  etc.  At  its  origin  the  facial  artery  lies  beneath 
the  posterior  belly  of  the  digastric  and  stylo-hyoid  muscles  close  to 
the  posterior  border  of  the  submaxillary  gland,  which  it  grooves  and 
supplies;  here  it  gives  off  its  submental  branch,  which  runs  forward 
upon  the  under  surface  of  the  mylo-hyoid  muscle  close  to  the  body 
of  the  lower  jaw.  From  its  posterior  aspect,  upon  a  level  with  the 
origin  of  the  facial,  the  external  carotid  artery  gives  off  its  occipital 
branch.  This  vessel  passes  upward  and  backward  across  the  internal 
jugular  vein  and  ascends  beneath  the  anterior  border  of  the  sterno- 
mastoid  muscle  to  reach  the  occipital  region  of  the  head.  Above  the 
origin  of  the  occipital,  also  from  its  posterior  aspect,  the  external  caro- 
tid gives  off  the  posterior  auricular.  This  vessel  courses  upward  and 
backward,  running  close  behind  the  ear  and  supplying  this  and  the 
mastoid  region.  The  hypoglossal  nen^e  swings  forward  across  the 
outer  side  of  the  external  carotid  artery  upon  a  level  with  the  origin 
of  the  occipital. 

The  Internal  Jugular  Vein  lies  close  to  the  outer  side  of 
the  common  carotid  artery  and  its  continuation,  the  internal  carotid. 
This  vessel  is  large,  as  big  around  as  the  little  finger,  very  thin 
walled,  and  lies  in  the  same  connective-tissue  bed  with  the  artery 
and  the  pneumogastric  ner\'e.  It  is  formed  above,  at  the  base  of 
the  skull,  by  the  union  of  the  lateral  (sigmoid)  and  inferior  petrosal 
sinuses.  These  vessels  emerge  from  the  interior  of  the  skull  through 
the  jugular  foramen,  which  is  situated  behind  and  external  to  the 
commencement  of  the  carotid  canal;  the  pneumogastric.  spinal  ac- 
cessory, and  giosso-pharyngeal  nerves  also  emerge  from  the  cranium 
through  the  jugular  foramen.  Just  outside  the  skull  the  lateral  and 
the  inferior  petrosal  sinuses  join  and  form  a  bulbous  dilatation,  which 
marks  the  commencement  of  the  internal  jugular  vein.  At  the  root 
of  the  neck  the  internal  jugailar  terminates  by  joining  with  the  sub- 
clavian to  form  the  innominate.  In  its  course  through  the  neck  the 
vein  receives  a  number  of  large  branches :  the  temporo-facial,  lingual, 
and  superior  and  middle  thyroids.  A  chain  of  lymphatic  nodes  is 
situated  along  the  outer  side  of  the  vein,  close  to  its  wall,  and  these 
may  be  diseased  and  require  extirpation.  On  the  right  side,  in  the 
root  of  the  neck,  where  the  internal  jugular  unites  with  the  sub- 


226  NECK  AND  TONGUE. 

clavian,  the  right  lymphatic  duct  is  seen  to  enter  the  vesseL  Upon 
the  left  side  of  the  neck  the  thoracic  duct  enters  the  vein  at  its  junc- 
tion with  the  subclavian. 

The  thoracic  duct  ascends  out  of  the  thorax  into  the  root  of 
the  neck,  arches  forward  and  outward  over  the  first  part  of  the  sub- 
clavian artery,  and  empties  into  the  internal  jugular  vein  in  the 
angle  formed  by  the  junction  of  this  vein  with  the  subclavian. 

The  Subclavian  Artery. — ^This  vessel  upon  the  right  side  is 
derived  from  the  innominate,  which  bifurcates  behind  the  right  sterno- 
clavicular articulation  into  the  common  carotid  and  subclavian.  The 
left  subclavian  is  given  off  from  the  left  end  of  the  transverse  part 
of  the  arch  of  the  aorta  and  ascends  in  the  upper  part  of  the  chest 
as  far  as  the  left  stemo-clavicular  articulation. 

From  the  stemo-clavicular  articulation,  upon  either  side,  the 
subclavian  artery  arches  outward  across  the  root  of  the  neck  and 
passes  into  the  axilla  to  become  the  axillary.  In  the  root  of  the  neck 
the  artery  is  found  in  the  subclavian  triangle  resting  directly  upon 
the  first  rib. 

The  tendon  of  the  scalenus  anticus,  at  its  attachment,  is  situated 
in  front  of  the  subclavian  artery,  and  thus,  for  purposes  of  descrip- 
tion, serves  to  divide  the  vessel  into  three  parts.  The  first  part  of  the 
artery  corresponds  to  that  portion  which  is  included  between  its  origin 
and  the  inner  margin  of  the  tendon  of  the  scalenus  anticus;  the 
second  part  of  the  artery  corresponds  to  the  portion  immediately 
behind  the  tendon  of  the  scalenus,  and  the  third  part  of  the  artery 
reaches  from  the  outer  border  of  the  tendon  of  the  scalenus  anticus 
to  the  point  where  it  enters  the  axilla  to  become  the  axillary.  The 
first  and  second  parts  of  the  artery  are  in  intimate  relation  with  the 
apex  of  the  lung  and  dome  of  the  pleura;  the  third  portion  rests 
upon  the  upper  surface  of  the  first  rib.  The  trunks  of  the  brachial 
plexus  in  their  course  through  the  subclavian  triangle  are  situated 
above  the  subclavian  artery.  The  subclavian  artery  gives  off  several 
large  branches;  from  its  first  part  the  vertebral,  internal  mammary, 
and  thyroid  axis  (inferior  thyroid,  suprascapular,  transversalis  colli)  ; 
from  the  second  part,  the  superior  intercostal.  The  origin  of  these 
branches  varies  in  different  individuals  and  in  the  same  individual 
upon  either  side. 

The  subclavian  vein  is  the  continuation  of  the  axillary.  It  passes 
inward  across  the  root  of  the  neck,  beneath  the  clavicle  and  in  front 
of  the  scalenus   anticus  tendon,  resting  upon  the  upper  surface  of 


SURGICAL  ANATOMY  OF  THE  NECK.  237 

the  first  rib  and  lying  in  front  and  to  tlie  inner  side  of  the  artery. 
It  is  situated  a  considerable  distance  away  from  the  artery,  from 
which  it  is  separated  by  the  tendon  of  the  scalenus  anticus.  The 
subclavian  vein  joins  with  the  internal  jugular  to  fonn  the  innomi- 
nate. Upon  the  right  side  where  these  two  veins  join  they  receive 
the  right  lymphatic  duct,  and  upon  the  left  side,  at  their  junction, 
they  receive  the  thoracic  duct. 

The  Inferior  Thyroid  Artery  is  seen  deep  in  the  lower  part 
of  the  inferior  carotid  triangle.  It  is  a  branch  of  the  thyroid  axis 
which  arises  from  the  first  part  of  the  subclavian.  The  inferior 
thyroid  artery  passes  upward  and  inward  along  the  inner  border  of 
the  scalenus  anticus  muscle.  In  this  part  of  its  course  it  lies  behind 
the  common  carotid  arter}\  Upon  a  level  with  or  just  below  the 
transverse  process  of  the  sixth  cervical  vertebra^this  process  is  readily 
identified  by  the  prominent  tubercle  which  marks  it,  the  tubercle  of 
Chassaignac — the  artery  turns  inward  toward  the  middle  of  the  poste- 
rior border  of  the  lateral  lobe  of  the  thyroid  gland.  The  artery  dis- 
appears underneath  the  border  of  the  gland  and  then  turns  downward 
toward" the  lower  pole  of  the  lobe,  where  it  breaks  up  into  a  number 
of  branches  to  enter  this  part  of  the  gland.  As  the  vessel  turns  in- 
ward upon  a  level  with  the  sixth  cervical  vertebra  it  lies  behind  the 
common  carotid  artery,  and  is  crossed  by  the  cervical  sympathetic 
nerve.  The  middle  cervical  ganglion  lies  in  front  of  the  artei^.  Just 
before  the  inferior  thyroid  artery  reaches  the  thyroid  gland  the  re- 
current laryngeal  nerve  passes  across  it,  usually  in  front  of  the  artery, 
sometimes  behind  it,  also  upon  the  level  of  the  transverse  process  of 
the  sixth  cervical  vertebra.  The  recurrent  laryngeal  nerve  of 
each  side  is  situated  well  behind  the  corresponding  lobe  of  the  thyroid 
gland  in  the  recess  between  the  trachea  and  oesophagus. 

The  Superior  Thyroid  Artery  is  the  first  branch  given  off 
from  the  external  carotid  just  above  the  bifurcation  of  the  common 
carotid,  about  upon  a  level  with  the  upper  border  of  the  thyroid 
cartilage.  The  artery  ascends  a  short  distance  and  then  curves  down- 
ward and  disappears  underneath  the  omohyoid  muscle  in  its  course 
to  the  upper  pole  of  the  lateral  lobe  of  the  thyroid  gland,  where 
it  divides  into  two  main  branches,  one  going  to  the  anterior  and 
the  other  to  the  posterior  surface  of  the  thyroid  gland.  The  artery 
is  accompanied  by  the  superior  thyroid  vein.  It  may  be  necessary  to 
ligate  the  superior  thyroid  vessels  in  cases  of  hyperthyroidism  pre- 
liminary to  extirpating  a  lobe. 


228  NECK  AND  TONGUE. 

The  Vertebral  Artery  lies  deep  in  the  lower  part  of  the  neck. 
It  arises  from  the  first  part  of  the  subclavian  between  the  scalenus 
anticus  muscle  in  front  and  the  longus  colli  behind  and  enters  the 
foramen  in  the  base  of  the  transverse  process  of  the  sixth  cervical 
vertebra.  The  prominent  tubercle  on  the  transverse  process  of  this- 
vertebra  is  a  good  guide  to  the  artery.  The  artery  may  be  reached 
through  the  subclavian  triangle  by  drawing  the  stemo-mastoid  forward 
toward  the  middle  line  or  by  nicking  or  incising  its  posterior  border. 

The  Cervical  Sympathetic  Nerves. — The  cervical  sympathetic  is 
found  deep  in  the  neck  behind  the  carotid  artery,  internal  jugular 
vein,  and  vagus  nerve,  resting  upon  the  prgevertebral  muscles — the 
rectus  capitis  anticus  major  above  and  the  longns  colli  below.  The 
nerve  lies  in  intimate  contact  with  these  muscles  beneath  the  fascia 
that  covers  them, — the  fascia  prsevertebralis.  At  the  root  of  the  neck 
the  ner^^e  descends  into  the  thorax. 

The  cervical  portion  of  the  sympathetic  is  marked  by  three 
swellings  or  ganglia, — the  superior,  middle,  and  inferior. 

The  superior  ganglion,  the  largest,  is  fusiform  in  shape  and 
about  one  inch  in  length.  It  is  found  resting  upon  the  rectus  cajoitis 
major  muscle  opposite  the  second  and  third  vertebrse,  behind  the 
internal  carotid  artery  and  to  the  inner  side  of  the  vagus  nerve. 
Among  other  branches  it  gives  off  the  superior  cardiac  nerve. 

The  middle  ganglion  is  the  smallest  of  the  three.  It  is  some- 
times absent  or  it  may  be  double.  It  is  situated  at  the  point  where 
the  spnpathetic  nerve  crosses  the  inferior  thyroid  artery,  opposite  the 
prominent  tul)ercle  on  the  transverse  process  of  the  sixth  vertebra,^ 
the  tubercle  of  Chassaignac.  This  ganglion  gives  off  thyroid  branches 
that  accompany  the  inferior  thyroid  artery  to  the  thj-roid  gland. 
The  middle  cardiac  nerve  is  derived  from  the  middle  ganglion. 

The  inferior  cervical  ganglion  is  larger  than  the  middle.  It  is 
irregTilar  in  shape  and  is  frequently  merged  with  the  first  thoracic 
ganglion.  It  is  situated  opposite  the  neck  of  the  first  rib,  between 
the  scalenus  anticus  and  longus  colli  muscles  and  under  cover  of 
the  vertebral  vessels.  A  branch  from  the  inferior  cervical  ganglion 
curves  around  the  subclavian  artery  and  ascends  to  communicate 
with  the  middle  cervical  ganglion;  it  is  called  the  ansa  Vieussenii. 
The  inferior  ganglion  gives  off  the  inferior  cardiac  nerve. 

Pupillo-dilator  fillers  are  derived  from  the  superior  ganglion 
through  branches  to  the  G-asserian  ganglion  and  then  through  the 
ophthalmic  division  of  the  fifth  and  the  long  ciliary  nei^ves. 


SURGICAL  ANATOMY  OF  THE  NECK.  229 

Branches  from  the  Diiddle  ganglion  are  distributed  to  the  thy- 
roid gland. 

Accelerator  fibers  to  the  heart  are  divided  from  all  three  gan- 
glia and  from  the  first  thoracic  ganglion. 

The  Cervical  Lymph-nodes. — These  are  pinkish  bodies  ranging 
in  size  from  a  small  bead  to  a  bean.  They  usually  occur  in  groups 
or  chains  along  the  course  of  the  large  veins.  Occasionally  they  are 
found  singly.  They  may  be  descril^ed  as  consisting  of  two  groups, 
superficial  and  deep.  Both  groups  communicate  freely  with  each 
other.  The  lympli -nodes  are  aggregations  of  lymph-tissue  situated 
along  the  course  of  the  lymphatic  vessels.  The  lymph-nodes  readily 
become  affected,  enlarged,  tender,  when  infectious  material,  absorbed 
by  the  capillary  lymph-spaces  and  channels,  reaches  them. 

The  Superficial  Lymph-nodes  are  lodged  in  the  subcutaneous 
connective-tissue  layer.  Just  underneath  the  skin,  between  the  super- 
ficial and  deep  fascia?.  They  are  situated  along  the  course  of  the  ex- 
ternal jugular  vein  and  its  tributaries.  The  superficial  lymph-nodes 
may  become  affected  in  connection  with  lesions  of  the  face,  neck, 
scalp.  They  tend  to  soften,  break  down,  and  open  through  the  skin. 
If  it  becomes  necessary  to  incise  them  the  skin  layer  only  need  be 
penetrated.  After  they  have  been  incised  and  evacuated  they  may  be 
swabbed  out  witli  tincture  of  iodin  and  packed  with  iodoform  gauze. 
If  enlarged  as  the  result  of  some  chronic  process  and  not  broken 
down,  they  may  be  shelled  out  readily  by  blunt  dissection. 

The  Deep  Cervical  Lymph-nodes. — They  are  found  deep  in 
the  neck,  underneath  the  deep  cervical  fascia,  in  the  connective-tissue 
spaces  along  the  course  of  the  great  vessels  of  the  neck.  They  are 
found  lying  very  close  to  the  walls  of  the  internal  jugular  vein  and 
its  tributaries.  The  different  groups  of  lymph-nodes  may  be  named 
according  to  their  situation  in  the  various  triangular  spaces  of  the 
neck.  The  deep  lymph-nodes  may  be  affected  secondarily  to  infec- 
tion of  the  superficial  or  they  may  become  enlarged  (swollen)  as  a 
result  of  infection  that  enters  through  the  tonsils  and  glandular 
tissue  of  the  naso-pharynx,  mouth,  base  of  the  tongue,  etc.  The  in- 
flammatory process  may  be  acute,  in  which  case  the  lymph-glands 
may  suppurate  and  break  down,  and  all  that  will  be  necessary  is  sim- 
ple incision  and  drainage.  Frequently  the  glands  are  found  to  be  the 
seat  of  tuberculous  disease.  They  become  swollen,  some  cheesy  in 
the  center;  others  suppurate  and  break  down.  Those  glands  that 
have  not  yet  broken  down  may  be  readily  enucleated.    Those  that  have 


230  NECK  AND  TONGUE. 

suppurated  are  often  very  firmly  adherent  to  adjacent  structures, 
walls  of  veins,  etc.,  and  require  much  care  in  dissecting  them  out. 
Operation  to  be  successful  must  be  thorough. 

Anatomically  and  a^.so  for  the  purpose  of  surgical  interference  the 
lymph-nodes  may  be  grouped  according  to  their  situation  in  the  vari- 
ous triangailar  spaces  as  follows : — 

Superior  carotid  triangle. 

Inferior  carotid  triangle. 

Submaxillary  triangle. 

Occipital  triangle. 

Subclavian  triangle. 

Less  frequently  gland-masses  are  found  in  the  front  of  the  neck, 
in  the  submental  triangle  and  in  the  laryngeal  region.  The  enlarged 
glands  may  be  fairly  well  confined  to  one  triangle  or  may  involve 
several  spaces  or  all  the  glands  of  one  or  both  sides  of  the  neck  may 
be  affected. 

OPERATIONS  UPON  THE  NECK. 

Lig-ation  of  Blood-vessels.  The  Common  Carotid  Arteey. — 
The  common  carotid  may  be  tied  either  above  or  below  the  point 
where  the  omo-hyoid  crosses  it,  which  is  upon  a  level  with  the  cricoid 
cartilage.  It  is  ligated  preferably  and  more  readily  in  the  so-called 
superior  carotid  triangle:    above  the  crossing  of  the  omo-hyoid. 

The  linear  guide  to  the  common  carotid  is  a  line  drawn  from 
a  point  midway  between  the  angle  of  the  Jaw  and  the  mastoid  process 
to  the  sterno-clavieular  articulation.  The  muscular  guide. is  the  an- 
terior border  of  the  sterno-mastoid  muscle. 

The  incision  is  made  about  two  inches  long,  corresponding  to 
the  anterior  border  of  the  sterno-mastoid,  its  midpoint  upon  a  level 
with  the  cricoid  cartilage.  This  incision  penetrates  through  the  skin 
and  subcutaneous  fatty  layer,  including  the  platysma,  and  should 
expose  the  anterior  border  of  the  sterno-mastoid  muscle.  The  edge 
of  the  sterno-mastoid  should  be  recognized  and  drawn  outward,  and 
then,  after  carefully  incising  the  underljdng  layer  of  deep  cervical 
fascia, — the  fascia  that  separates  the  vessels  from  the  sterno-mastoid 
muscle, — the  vessels,  surrounded  by  some  loose  connective  tissue,  are 
exposed — first,  the  internal  jugular  vein,  big  and  thin-walled,  lying 
to  the  outer  side  of  the  artery,  and  then  the  common  carotid,  whose 
pulsation  is  readily  felt  and  seen  and  which  lies  to  the  inner  side 
of   the   vein.      The   pneumogastric  nerve,   which   is   located   between 


OPERATIONS  UPON  THE  NECK. 


231 


the  artery  and  vein,  but  behind  them,  is  not  seen.  The  anterior  belly 
of  the  omo-hyoid  is  seen  as  it  crosses  the  vessels  opposite  the  cricoid 
cartilage.  The  loop  formed  by  the  descendens  and  communicans  noni 
may  also  be  recognized  upon  the  front  of  the  vessels.  The  superior 
thyroid  vein  crosses  the  artery  from  within  outward  above  the  omo- 
hyoid muscle,  and  the  middle  thyroid  vein  below  this  muscle.  If 
these  vessels  are  cut,  they  should  be  clamped  and  tied. 

The  connective-tissue  sheath  which   incloses  the   artery  should 
be  picked  up  with  mouse-tooth  forceps,  and  nicked  with  the  point 


Fig.  138. — A,  incision  for  removal  of  lower  jaw;  B,  Incision  for  ligation  of 
lingual  artery  and  Kocher's  amputation  of  tongue;  C,  incision  for  ligation  of 
common  carotid  and  for  oesophagotomy. 


of  the  knife  in  the  direction  of  the  long  axis  of  the  vessels;  into  the 
opening  thus  made,  a  director  is  introduced,  and,  working  close  to 
its  wall,  the  vessel  is  separated  all  around,  taking  care  to  avoid  the 
pneumogastric  nerve,  which  lies  posteriorly.  A  blunt-pointed  aneurism 
needle  is  then  introduced  into  the  opening  and  carried  around  the 
artery  from  without  inward,  entering  between  the  artery  and  the 
vein.  The  ligature  is  then  drawn  around  the  vessel,  and  we  are  ready 
to  tie.  The  ligature  should  be  of  ordinary  catgiit  and  tied  with  a 
square  knot.     After  the  ligature  is  in  place  and  before  it  is  tied  the 


232  ■  NECK  AND  TONGUE. 

parts  should  be  again  inspected  in  order  to  make  sure  that  the  nerve 
is  not  included.  Some  surgeons  tie  the  artery  double  and  divide  it 
between  the  ligatures,  but  this  is  probably  unnecessary.  The  incision 
is  closed  with  a  catgut  suture. 

The  External  Carotid. — The  ligation  of  the  external  carotid 
is  practiced  as  a  preliminary  to  many  bloody  operations  about  the 
mouth,  jaws,  etc.,  and  to  control  hemorrhage  from  parts  supplied  by 
its  branches  when  the  branches  themselves  are  not  accessible.  The 
linear  guide  to  the  artery  is  the  same  as  that  for  the  common  carotid ; 
the  muscular  guide  is  the  anterior  edge  of  the  stemo-mastoid.  At 
the  upper  border  of  the  thyroid  cartilage  the  common  carotid  artery 
bifurcates  into  the  external  and  internal  carotids,  and  it  is  close  to  its 
origin,  near  the  upper  border  of  the  thyroid  cartilage,  that  the  ex- 
ternal carotid  is  ligated.  The  incision  commences  at  the  level  of  the 
hyoid  bone  and  is  carried  downward,  for  a  distance  of  about  two 
inches,  along  the  anterior  border  of  the  sterno-mastoid.  The  in- 
cision penetrates  through  the  skin,  fat,  and  platysma  mAiscle  down 
to  the  deep  cervical  fascia,  exposing  the  edge  of  the  sterno-mastoid 
muscle,  which  should  be  recognized.  The  edges  of  the  incision  are 
drawn  apart  with  blunt-pronged  retractors  and  the  deep  cervical  fascia 
is  then  incised. 

The  pulsation  of  the  arter}",  within  its  connective-tissue  sheath, 
may  now  be  both  seen  and  felt.  The  external  carotid  artery  lies  a 
little  in  front  of  the  anterior  edge  of  the  sterno-mastoid.  The  in- 
ternal carotid,  together  with  the  internal  jugular  vein  and  pneumo- 
gastric  nerve,  lies  posterior  to  the  external  carotid,  beneath  the  an- 
terior edge  of  the  sterno-mastoid.  Con-esponding  to  the  upper  border 
of  the  thj^roid  cartilage,  the  loose  connective  tissue  that  invests  the 
artery  is  picked  up  with  a  thumb  forceps  and  snipped  with  the  point 
of  the  knife,  cutting  in  a  direction  corresponding  to  the  long  axis 
of  the  vessel;  into  the  opening  wliich  is  thus  made  a  blunt  director 
is  introduced  and  worked  around  the  vessel,  sticking  close  to  its  wall. 
Through  the  path  thus  made  by  the  director  a  ligature  is  carried  around 
the  vessel  in  the  eye  of  an  aneurism  needle.  The  ligature  is  then 
tied  and  the  incision  closed.  After  the  ligature  has  been  carried 
around  the  artery  it  may  be  left  untied,  with  its  ends  hanging  out 
of  the  incision,  to  be  tied  only  in  case  an  emergency  arises  calling 
for  its  use. 

The  Internal  Carotid. — The  ligation  of  the  internal  carotid 
is  but  seldom  called  for.     The  internal  carotid  may  be  tied  through 


OPERATIONS  UPON  THE  NECK.  233 

an  incision  similar  to  that  for  ligation  of  the  external  carotid.  The 
vessel  is  found  underneath  the  anterior  edge  of  the  sterno-mastoid, 
which  is  the  muscular  guide  to  it.  The  internal  carotid  has  the 
same  relations  to  the  internal  jugular  vein  and  pneumogastric  nerve 
that  the  common  carotid  has,  the  internal  carotid  being  really  the 
continuation  of  the  common;  and  these  structures  must  be  avoided, 
in  isolating  the  vessel  and  passing  the  ligature. 

The  Subclavian  Artery. — The  third  part  of  the  subclavian 
arten-  is  tied  after  it  is  exposed  in  the  subclavian  triangle. 

The  patient  is  placed  with  the  shoulders  somewhat  raised  and 
the  head  thrown  back  and  turned  toward  the  opposite  side,  the  arm 
being  drawn  down  to  depress  the  shoulder.  The  incision  corresponds 
to  the  middle  third  of  the  clavicle.  It  is  placed  just  above  the  clavicle, 
and  extends  from  the  anterior  border  of  the  trapezius  forward  and 
inward  almost  as  far  as  the  outer  border  of  the  sterno-mastoid  muscle ; 
the  incision  falls  a  little  short  of  the  edge  of  the  sterno-mastoid 
muscle  in  order  to  avoid  the  external  jugular  vein.  The  incision 
in  the  skin  may  be  made  by  drawing  the  integniment  of  the  neck 
downward  over  the  surface  of  the  clavicle  and  then  cutting  through 
it,  down  upon  the  surface  of  the  clavicle;  when  the  skin  is  released, 
the  incision  is  found  to  lie  just  above  and  parallel  with  the  clavicle. 
This  incision  reaches  through  the  skin,  fat,  and  platysma  down  to 
the  deep  fascia.  The  deep  fascia,  which  reaches  from  the  edge  of 
the  trapezius  muscle  behind  to  the  sterno-mastoid  in  front,  is  now 
incised,  avoiding  the  external  jugular  vein,  which  pierces  the  deep 
cervical  fascia  behind  the  outer  edge  of  the  sterno-mastoid  muscle. 
Beneath  the  deep  fascia  the  venous  plexus,  formed  by  the  transversalis 
colli  and  suprascapular,  is  encountered.  These  veins  may  be  wounded, 
but  are  readily  clamped ;  often,  however,  they  can  be  avoided,  as  the 
knife  may  be  discarded  after  the  deep  fascia  has  been  incised.  Beneath 
the  deep  fascia  there  is  also  a  considerable  quantity  of  loose  fat  and 
connective  and  honphatic  tissue. 

The  posterior  belly  of  the  omo-hyoid  muscle,  which  lies  pretty 
low  down  near  the  clavicle,  is  now  sought  and  must  be  drawn  upward 
to  show  the  subclavian  triangle,  of  which  it  forms  the  upper  bound-. 
ary,  the  anterior  boundary  being  formed  by  the  stemo-mastoid  and 
the  inferior  boundary  by  the  clavicle. 

Within  the  triangle,  passing  transversely  outward,  are  the  trans- 
versalis colli  and  suprascapular  arteries.  These  vessels  should  be 
avoided.     The  tendon  of  the  scalenus  anticus,  which  is  the  guide  to 


234  NECK  AND  TONGUE. 

the  subclavian  artery,  may  be  felt  as  a  tense  cord  passing  straight 
lip  and  down  beneath  the  posterior  or  outer  border  of  the  stemo- 
mastoid  and  attached  below  to  the  first  rib.  The  phrenic  nerve  passes 
obliquely  downward  across  the  front  of  the  tendon  of  the  scalenus 
anticus  into  the  thorax.  If  this  tendon  is  followed  downward  as 
far  as  its  attachment  to  the  first  rib,  one  may  locate  the  subclavian 
artery  as  it  passes  outward  and  forward  from  behind  the  tendon  of 
the  scalenus  anticus  muscle,  resting  directly  upon  the  upper  surface 
of  the  first  rib.  That  part  of  the  subclavian  artery  which  lies  upon 
the  first  rib  is  the  part  which  is  ligated.  The  subclavian  vein  lies  a 
considerable  distance  to  the  inner  side  of,  and  anterior  to,  the  artery, 
the  tendon  of  the  scalenus  anticus  intervening  between  them,  and 
is  not  apt  to  be  encountered  during  the  operation.  Within  the  tri- 
angle, above  the  subclavian  artery,  may  be  seen  the  three  cords  of 
the  brachial  plexus.  These  pass  obliquely  downward  and  outward 
from  behind  the  scalenus  anticus  muscle,  and  should  not  be  mistaken 
for  the  artery,  which  is  the  lowest  structure  in  this  triangle  and  rests 
directly  upon  the  upper  surface  of  the  first  rib.  These  structures 
may  all  be  exposed  by  blunt  dissection,  separating  with  the  finger  or 
handle  of  the  knife,  after  the  deep  fascia  has  been  incised. 

With  blunt  retractors  the  wound  is  held  open  and  the  connective- 
tissue  sheath,  which  envelops  the  arter}^,  picked  up  and  snipped  with 
the  scissors  and  the  artery  then  separated  from  the  adjoining  struc- 
tures with  a  blunt  director,  working  around  the  artery  close  to  its 
wall.  The  aneurism  needle  is  passed  around  the  artery  from  without 
inward,  avoiding  the  cords  of  the  brachial  plexus.  The  subclavian 
vein,  which  lies  below  and  internal  to  the  artery,  is  not  apt  to  be  in 
the  way. 

It  should  also  be  remembered  that  the  dome  of  the  pleura  reaches 
above  the  clavicle  into  the  subclavian  triangle,  and  that  the  subclavian 
artery  (second  part),  as  it  lies  behind  the  tendon  of  the  scalenus 
anticus,  rests  upon  the  pleura,  and  care  should  be  taken  to  avoid 
injuring  this  structure,  especially  in  making  way  for  the  passage  of 
the  ligature. 

The  ligature  is  tied  with  a  square  knot,  deep  in  the  wound, 
without  lifting  the  artery  too  much  out  of  its  bed. 

The  Lingual  Artery. — This  artery  is  usually  ligated  prelimi- 
nary to  amputation  of  the  tongue.     For  incision,  etc.,  see  page  262. 

The  Superior  Thyroid  Artery. — The  superior  thyroid  artery 
is  ligated  during  the  course  of  operations  upon  the  thyroid  gland. 


OPERATIONS  UPON  THE  NECK.  235 

The  artery,  together  with  the  superior  thj-roid  vein  which  accom- 
panies it,  is  found  close  to  its  origin  in  the  space  between  the  upper 
border  of  the  thyroid  cartilage  and  the  lateral  horn  of  the  hyoid  bone. 
The  arteiy  and  vein  are  picked  up  on  the  l)lunt  ligature  carrier 
and  tied. 

The  superior  thyroid  arteries  of  both  sides  may  be  ligated  some 
days  or  weeks  before  undertaking  extirpation  of  the  thyroid  gland 
in  cases  of  exophthalmic  goitre,  where  the  symptoms  are  so  exag- 
gerated as  to  counterindicate  the  more  radical  operation. 

The  incision,  about  two  and  one-half  inches  long,  is  made  from 
the  anterior  edge  of  one  stemo-mastoid  muscle,  across  the  front  of 
the  neck,  to  the  anterior  edge  of  the  other.  The  incision  follows  the 
natural  crease  of  the  neck  and  is  placed  just  above  the  cricoid  cartilage, 
midway  between  the  cricoid  cartilage  and  the  hyoid  bone.  The  artery 
is  found  just  underneath  the  deep  fascia,  close  to  its  origin  from 
the  external  carotid,  in  the  space  between  the  upper  border  of  the 
thyroid  cartilage  and  the  lateral  horn  of  the  hyoid  bone.  The  su- 
perior thyroid  vein  is  included  with  the  artery  in  the  ligature.  The 
vessels  are  picked  up  upon  the  blunt  ligature-carrier  and  tied  with 
twenty-day  catgut. 

The  Inferior  Thyroid  Artery.- — This  vessel  is  ligated  during 
the  course  of  operation  upon  the  thyroid  gland.  This  artery  is  the 
largest  branch  of  the  thyroid  axis.  It  ascends  deep  in  the  root  of 
the  neck  along  the  inner  border  of  the  scalenus  anticus  muscle  and 
opposite  the  prominent  anterior  tubercle  of  the  sixth  cervical  vertebra, 
the  tubercle  of  Chassaignac,  passes  inward  behind  the  common  carotid 
arter}",  etc.,  to  reach  the  lower  part  of  the  lateral  lobe  of  the  thyroid 
gland.  It  is  crossed  by  the  sympathetic  nerve,  the  middle  cervical 
ganglion  resting  upon  the  artery  either  anterior  or  posterior  to  it. 
The  recurrent  larj-ngeal  nerve  as  it  ascends  in  the  root  of  the  neck 
a' so  crosses  the  artery. 

An  incision  about  three  inches  in  length  is  made  along  the  ante- 
rior border  of  the  sterno-mastoid  reaching  downward  as  far  as  the 
clavicle.  The  incision  extends  through  the  skin  and  fat  down  to  the 
deep  cervical  fascia.  This  layer  is  divided  in  front  of  the  sterno- 
mastoid  and  the  common  carotid  artery  and  adjacent  structures,  in- 
ternal jugular  vein,  pneumogastric  nerve,  drawn  outward  with  a  blunt 
hook.  With  the  finger  in  the  wound,  the  tubercle  on  the  transverse 
process  of  the  sixth  cervical  vertebra  is  sought.  This  is  the  guide  to 
the  artery.    At  this  level  the  vessel  passes  inward  to  reach  the  lateral 


236  NECK  AND  TONGUE. 

lobe  of  the  thyroid  gland.  A  ligature  is  carried  around  the  vessel  with 
an  aneurism  needle  and  securely  tied.  The  ligature  should  be  applied 
to  the  vessel  some  little  distance  away  from  the  thyroid  gland  so  as 
to  avoid  the  inferior  recurrent  laryngeal  nerve  which  passes  across 
the  arter}^  as  it  ascends  in  the  neck. 

Facio-hypoglossal  Nerve  Anastomosis. — The  facial  nerve  is  oc- 
casionally injured,  divided,  during  the  course  of  operations  upon 
the  mastoid  antrum,  result  of  gun-shot,  etc.,  and  it  may  be  desirable 
to  make  an  anastomosis  between  its  peripheral  portion  and  the  prox- 
imal portion  of  some  other  nerve — ^the  hypoglossal  or  spinal  acces- 
sory— ^with  the  object  of  correcting  the  paralysis  of  the  muscles  of 
the  face,  etc.  Usually  the  hypoglossal  is  selected  because  of  the  fact 
that  its  nucleus  of  origin  is  quite  adjacent  to  that  of  the  facial; 
it  is  quite  readily  accessible  in  the  neck,  and  the  paralyses  resulting 
from  its  division  are  not  so  objectionable,  etc. 

The  facial  nerve  is  reached  through  an  incision  that  commences 
above,  just  behind  the  ear,  above  and  in  front-  of  the  tip  of  the 
mastoid  process,  and  passes  downward  along  the  anterior  border  of  the 
sterno-mastoid  muscle  as  far  as,  or  beyond,  the  level  of  the  hyoid 
bone.  The  nerve  is  sought  deep  in  the  parotid  space,  between  the 
ramus  of  the  jaw  in  front  and  the  mastoid  process  behind.  The 
parotid  gland  is  exposed  and  detached  posteriorly  so  that  it  may  be 
drawn  well  forward  with  the  blunt-pronged  tractor.  The  sterno- 
mastoid  muscle  is  retracted  toward  the  back.  All  hemorrhage  must 
be  controlled  so  that  the  wound  is  dry.  The  nerve  may  be  seen  as 
it  passes  forward  external  to  the  styloid  process  and  the  posterior 
belly  of  the  digastric  muscle  on  its  way  to  enter  the  parotid  gland. 
It  enters  the  posterior  border  of  the  parotid  g^and  about  one  cm. 
above  and  one  cm.  internal  to  the  tip  of  the  mastoid  process.  The 
nerve  is  followed  up  toward  the  stylo-mastoid  foramen  and  cut  square 
through  as  high  up  as  possible,  and  the  end  brought  down  ready 
for  anastom±osis  with  the  nerve  chosen  for  the  purpose — ^usually  the 
hypoglossal. 

The  hypoglossal  nerve  is  sought  in  the  lower  part  of  the  incision. 
The  nerve  is  found  as  it  curves  from  behind,  forward,  across  the 
external  carotid  artery,  just  above  the  point  where  the  common  carotid 
bifurcates  and  just  behind,  the  posterior  belly  of  the  digastric  muscle. 
The  hypoglossal  is  cut  and  the  proximal  end  brought  up  to  meet 
the  distal  end  of  the  facial.  The  ends  of  the  nerves  are  joined  to- 
gether accurately  with  several  very  fine  silk  or  catgut  sutures.     The 


OPERATIONS  UPON  THE  NECK. 


237 


sutures  are  introduced  with  a  fine  needle,  and  should  include  only 
the  sheaths  of  the  nerves  in  their  l)ite. 

Occasionally  it  is  necessary  to  expose  and  stretch  the  facial  nerve 
for  spasm  of  the  facial  muscles. 

Resection  of  Cervical  Sympathetic  (Jonnesco). — Total  Inlateral 
resection  of  the  cervical  sympathetic  including  the  three  cervical 
ganglia  and  the  first  thoracic  ganglion.     The  operation  is  done  for 


Fig.  139.— Fascio-hypoglossal  Anastomosis  (Frazier).  The  Stump  of  the  Facial 
Xerve  has  been  turned  down  and  Anastomosed  to  the  Stump  of  the  Hypoglossal. 
D.,  digastric  muscle;  E.G.,  external  carotid  artery;  F.H.,  anastomosed  facial  and 
hypoglossal  nerves;  M.P.,  mastoid  process;  Oc,  occipital  artery;  S.M.,  sterno- 
mastoid  muscle. 

the  cure  of  exophthalmic  goitre  ('Basedow's  disease) .  An  interval 
of  about  two  weeks  should  elapse  between  the  first  operation  for  ex- 
tirpation of  the  nerve  on  the  one  side  and  the  second  operation  for 
extirpation  of  the  nerve  on  the  other  side. 

Two  incisions  are  made, — one  in  the  upper  part  of  the  neck  in 
order  to  reach  the  superior  ganglion,  and  one  on  the  lower  part  of 
the  neck  to  gain  access  to  the  middle  and  inferior  ganglia,  etc. 

The  upper  incision  commences  at  the  posterior  border  of  the 
mastoid  process,  and  is  carried  downward  along  the  posterior  border 


238  NECK  AND  TONGUE. 

of  the  sterno-mastoid  for  a  distance  of  about  5  cm.  After  pene- 
trating between  the  fibers  of  the  sterno-mastoid  muscle,  the  layer  of 
deep  cervical  fascia  that  lines  its  under  surface  is  incised.  The  finger 
is  then  introduced  into  the  wound  and  the  sterno-mastoid  is  sep- 
arated bluntly  from  prevertebral  muscles  that  lie  beneath  it.  This 
separation  is  not  difficult,  the  finger  working  in  the  natural  connective- 
tissue  space  that  exists  between  the  fascia  that  lines'  the  deep  surface 
of  the  sterno-mastoid  and  that  which  covers  the  prasvertebral  mus- 
cles, the  fascia  prsevertebralis.  With  the  finger  this  separation  is 
carried  as  far  upward  as  the  base  of  the  skull  and  as  far  downward 
toward  the  root  of  the  neck,  as  the  finger  can  reach.  With  a  blunt 
retractor  the  sterno-mastoid,  together  with  the  internal  jugular  vein, 
internal  carotid  artery,  and  vagais  nerve,  is  drawn  well  forward  and 
the  sympathetic  nerve  sought.  The  nerve  is  found  lying  upon  the 
prgevertebral  muscles,  to  the  inner  side  of  the  anterior  tubercles  of 
the  transverse  processes  and  underneath  the  fascia  prsevertebralis. 
When  this  layer  of  fascia  is  snipped  through  the  nerve  comes  into 
view,  and  is  readily  identified  by  the  thickened  portion  that  represents 
the  superior  ganglion. 

The  lower  end  of  the  ganglion  is  grasped  with  an  artery  forceps 
and  the  trunk  of  the  nerve  followed  upward  as  far  as  the  base  of 
the  skull.  All  the  branches  that  it  gives  off  are  cut  with  the  scissors 
and  the  nerve  then  seized  as  high  as  possible  above  the  ganglion  and 
with  gradually  increasing  traction  it  is  torn  away.  The  end  of  the 
nerve  with  the  forceps  still  attached  is  brought  out  through  the  in- 
cision.    The  wound  is  temporarily  packed  with  gauze. 

A  second  incision  is  made  in  the  lower  part  of  the  neck.  It 
commences  just  above  the  clavicle  and  extends  upAvard,  correspond- 
ing to  the  posterior  border  of  the  sterno-mastoid  for  about  4  cm. 
The  posterior  edge  of  the  sterno-mastoid  is  exposed  and  then,  after 
incising  the  underlying  layer  of  deep  cervical  fascia,  the  finger  is 
introduced  into  the  wound.  The  finger  enters  the  lower  part  of  the 
same  connective-tissue  space  that  was  already  explored  with  the  finger 
through  the  upper  incision.  The  finger  is  pushed  downward  in  the 
space  as  far  as  the  clavicle  or  first  rib.  A  blunt  retractor  is  then 
introduced  and  the  edge  of  the  sterno-mastoid — together  with  the 
"bundle  of  structures  consisting  of  the  internal  jugular  vein,  carotid 
artery,  vagus  nerve,  etc. — is  drawn  toward  the  middle  line  and  the 
wound  thus  opened  wide.  The  inferior  thyroid  artery  is  sought.  It 
crosses  the  root  of  the  neck  upon  a  level  with  the  prominent  anterior 


OPERATIONS  UPON  THE  NECK.  239 

tubercle  of  the  transverse  process  of  the  sixth  vertebra, — the  tubercle 
of  Chassaignac.  The  middle  cervical  ganglion  is  found  usually  be- 
hind, though  sometimes  in  front  of  the  inferior  thyroid  artery.  At 
times  the  ganglion  is  absent  and  represented  by  a  plexus  that  sur- 
rounds the  inferior  thyroid  artery;  or  this  plexus  may  be  absent;,  the 
trunk  of  the  nerve  passing  down  across  the  artery  without  any  in- 
terruption. Traction  may  be  made  upon  the  nen-e  in  the  upper  and 
lower  incision  in  order  to  positively  identify  it. 

With  the  director  the  nerve  is  separated  and  raised  from  its 
bed,  working  simultaneously  through  both  the  upper  and  lower  in- 
cisions, and  is  then  drawn  down  and  out  through  the  lower  inci- 
sion. The  detachment  of  the  nerve  where  it  crosses  the  inferior 
thyroid  artei'y  is  easier  when  it  descends  in  front  of  the  vessel.  As 
a  rule,  the  nerve  descends  behind  the  artery.  The  branches  that 
are  distributed  from  the  ganglion  to  the  artery  must  be  divided; 
also  the  median  cardiac  nerve  which  may  be  identified  by  its  course 
inward,  and  the  anterior  branch  of  the  ansa  Vieussenii.  The  trunk 
is  then  drawn  down  under  the  artery. 

Following  the  course  of  the  nerve  downward  the  inferior  gan- 
glion is  reached.  This  ganglion  is  situated  behind  the  clavicle^,  rest- 
ing upon  the  neck  of  the  first  rib,  between  the.  scalenus  anticus  and 
longus  colli  muscles,  partly  covered  by  the  vertebral  vein  and  arteiy. 
The  nerve  is  seized  with  the  forceps  near  the  ganglion  and  drawn  a 
little  upward  and  the  vertebral  vein  which  covers  the  ganglion  ex- 
posed and  drawn  outward  with  a  blunt  hook;  likewise  the  vertebral 
artery.  There  is  then  exposed  to  view  the  inferior  ganglion  with 
its  many  small  branches,  including  the  nervus  cardiacus  inferior 
and  nervus  vertebralis.  These  branches  are  all  divided  with  the 
scissors.  The  further  separation  of  the  ganglion  is  made  with  the 
fingers  working  downward  past  the  first  thoracic  ganglion,  which  is 
also  detached.  As  the  final  step  of  the  operation  the  first  thoracic 
ganglion  is  seized  with  the  forceps  and  with  gradually  increasing 
traction  is  torn  out.  The  entire  cervical  sympathetic,  including  its 
three  ganglia,  and  the  first  thoracic  ganglion  are  thus  extirpated.  The 
incisions  are  closed  with  suture  without  drainage. 

The  most  difficult  part  of  the  operation  is  the  separation,  etc., 
of  the  inferior  cervical  ganglion.  The  subclavian  artery  lies  at  a 
deeper  level  and  is  not  usually  encountered.  The  phrenic  nerve  lies 
to  the  outer  side  crossing  the  scalenus  anticus  obliquely  from  above 
downward. 


24:0  KECK  AND  TONGUE. 

The  plan  of  operating  through  two  short  incisions  avoids  divi- 
sion of  the  superficial  branches  of  the  cervical  plexus,  the  spinal  ac- 
cessory nerve,  and  the  external  jugular  vein. 

Cervical  Adenectomy. — Eemoval  of  the  lymph-nodes  of  the  neck 
for  tuberculosis,  adeno-sarcoma,  etc.  The  incision  varies  according 
to  the  location  of  the  affected  glands  and  whether  those  in  one  tri- 
angle or  those  in  several  triangles  are  involved. 

Superior  and  Inferior  Carotid  Triangles. — To  expose  the 
chain  of  glands  underneath  the  anterior  border  of  the  sterno-mastoid 
muscle,  in  the  superior  and  inferior  carotid  triangles,  an  incision 
is  made  along  the  anterior  border  of  the  sterno-mastoid  muscle 
through  the  skin  and  fat.  The  external  Jugular  and  some  of  its 
tributaries  will  be  encountered  in  the  fat  layer.  These  are  clamped 
and  ligated  when  cut  or  they  may  be  recognized  and  ligated  double 
before  they  are  cut.  The  fascia  is  then  incised  along  the  anterior 
edge  of  the  sterno-mastoid  muscle,  plainl}^  exposing  the  fibers  of 
the  muscle.  The  edge  of  the  sterno-mastoid  is  an  importaiit  land- 
mark. The  edges  of  the  incision  are  drawn  widely  apart  with  Islunt- 
pronged  tractors.  The  layer  of  deep  cervical  fascia  is  next  incised 
and  the  diseased  gland  mass  thus  exposed.  The  incision  should  be 
sufficiently  large  to  freely  expose  the  mass.  Glands  which  have  not 
already  broken  down  may  be  seized  with  the  fingers  or  with  a  volsella 
forceps  and  enucleated  by  blunt  dissection  with  the  fingers  or 
blunt-pointed,  curved  scissors.  It  may  be  necessary  to  snip  occasional 
connective-tissue  strands  with  the  scissors.  They  are  cut  very  close 
to  the  gland  mass.  Glands  that  have  suppurated  will  be  found  more 
intimately  attached  to  the  adjacent  structures  through  adhesions  re- 
sulting from  periadenitis.  These  glands  are  pulled  upon — not  too 
forcibly — and  are  dissected  free  from  the  immediately  adjacent  parts 
with  the  blunt-pointed,  cun^ed  scissors,  with  the  fingers,  etc.,  working 
close  to  the  surface  of  the  gland  mass  and  making  moderate  traction 
at  the  same  time.  Usually  during  the  course  of  the  dissection  the 
internal  jugular  vein  or  in  dissection  of  the  upper  carotid  triangle, 
the  large  temporo-facial  branch  will  be  exposed.  In  removing  gland 
masses  that  lie  in  close  relation  to  these  vessels  it  is  desirable  to 
deliberately  expose  the  vessels  and  clean  them  away  from  the  gland 
mass.  With  the  vessels  thus  exposed  there  is  much  less  danger  of 
wounding  them,  and  if  they  are  accidentally  torn  or  incised  it  is  com- 
paratively easy  to  secure  the  bleeding  point  and  ligate  it.  It  is  dan- 
gerous to  operate  deep  in  the  neck  through  a  small  incision.     It  is 


OPERATIONS  LTON  THE  NECK.  241 

necessary  to  see  plainly  and  to  recognize  structures  as  they  are  met 
during  the  progress  of  the  operation.  Sudden  profuse  hemorrhage 
which  cannot  be  located  is  best  controlled  by  making  compression 
with  the  finger  in  the  wound.  The  wound  is  wiped  dry  and  upon 
removing  the  finger  the  point  from  which  the  blood  comes  is  seen  and 
secured.  The  large  veins  and  the  hemorrhage  that  may  result  if 
they  are  cut  are  practically  the  only  obstacles  encountered  during 
the  course  of  operations  in  this  part  of  the  neck. 

The  gland  masses  may  extend  forward  into  the  submaxillary 
triangle,  and  it  will  then  be  necessary  to  carry  another  incision 
forward,  above  and  parallel  with  the  hyoid  bone,  and  curving  up- 
ward toward  the  middle  of  the  chin.  Occasionally  it  will  be  necessary 
to  divide  the  sterno-mastoid  muscle  in  order  to  reach  diseased  glands 
which  lie  well  underneath  the  muscle.  Usually  partial  division  of 
the  muscle  will  suffice.  The  ends  of  the  muscle  are  reunited  by  several 
mattress   sutures  of   chromic   catgut. 

All  bleeding  points  must  be  secured  and  ligated  before  closing 
the  incision. 

The  wound  is  packed  with  iodoform  gauze  and  the  incision  is 
closed  with  interrupted  silk-worm  sutures  except  at  the  lower  end, 
where  the  gauze  drain  emerges.  The  drain  is  removed  on  the  fourth 
or  fifth  day. 

Submaxillary  Triangle. — Gland  masses  may  extend  into  this 
space  from  the  carotid  triangles  or  they  may  be  limited  to  this  space 
alone.  This  space  is  opened  up  by  an  incision  that  commences  at 
the  anterior  border  of  the  stemo-mastoid  muscle  upon  a  level  with 
the  angle  of  the  Jaw;  it  passes  downward  and  fonvard  to  the  hjoid 
bone,  then  forward  above  and  parallel  with  the  hyoid  bone,  and  ter- 
minates by  cuiTing  upward  toward  the  middle  of  the  chin.  The 
incision  penetrates  the  skin,  fat,  and  the  platysma  down  to  the  deep 
fascia.  The  facial  vein  will  be  exposed  and  may  be  divided,  and  will 
require  ligation.  The  deep  fascia  is  next  incised,  thus  opening  up 
the  contents  of  the  triangle.  In  enucleating  diseased  lymph-glands 
from  this  triangle,  especially  toward  the  back,  the  facial  artery  and 
the  temporo-facial  vein  which  empties  into  the  internal  jugular  will 
be  exposed  and  may  require  ligation. 

Posterior  or  Occipital  Triangle. — This  triangle  may  con- 
tain enlarged  lymph-nodes — tuberculous,  sarcomatous,  etc. — that  re- 
quire excision.  To  expose  the  contents  of  this  triangle  an  incision 
is  made  along  the  posterior  border  of  the  sterno-mastoid  muscle  down 

16 


342  NECK  AND  TONGUE. 

through  the  skin  and  fat  la3'ers.  The  external  jugular  vein  or  its 
large  tributary,  the  posterior  jugular,  may  be  divided  in  making 
this  incision  and  will  require  ligature.  The  posterior  edge  of  the 
sterno-mastoid  is  exposed — it  is  a  good  landmark, — and  is  drawn  for- 
ward with  the  blunt-pronged  retractor.  The  deep  fascia  is  then 
incised  and  the  gland  masses  are  exposed  and  may  be  enucleated. 
The  spinal  accessory  nerve  passes  across  this  triangle.  It  appears  at 
the  posterior  border  of  the  sterno-mastoid  muscle  at  the  junction  of 
its  upper  and  middle  thirds,  and  passes  obliquely  downward  and  back- 
ward across  the  space,  and  disappears  under  the  anterior  edge  of 
the  trapezius  muscle,  which  it  supplies.  If  the  nerve  is  touched  or 
pulled  upon  the  trapezius  contracts  and  indicates  that  the  nerve  is 
in  evidence. 

It  may  be  necessary  to  continue  the  dissection  down  into  the 
subclavian  triangle.  In  this  case  the  incision  is  prolonged  down 
along  the  posterior  border  of  the  sterno-mastoid  as  far  as  its  attach- 
ment to  the  clavicle,  and  from  the  lower  end  of  this  incision,  another 
is  carried  outward,  above  and  parallel  with  the  clavicle,  as  far  as 
the  edge  of  the  trapezius. 

SuBCLAviAiSr  Triangle. — This  space  often  contains  diseased 
lymph-glands^ — tuberculous,  sarcomatous,  carcinomatous — continuous 
with  the  glands  in  the  axillary  space. 

In  order  to  expose  the  contents  of  this  space  an  incision  is 
made  wliich  runs  above  and  parallel  with  the  clavicle,  from  the 
posterior  border  of  the  sterno-mastoid  to  the  anterior  edge  of  the 
trapezius.  From  the  inner  end  of  this  incision  another  is  carried 
upward  along  the  posterior  edge  of  the  sterno-mastoid  for  a  sufficient 
distance  to  give  free  access  to  the  space.  The  incision  goes  through 
the  skin  and  fat  layers  down  to  the  deep  fascia.  The  lower  end 
of  the  external  jugular  vein,  just  before  it  pierces  the  deep  cervical 
fascia,  may  be  exposed  and  may  require  ligation.  Next,  the  deep 
fascia  is  incised  when  the  gland  mass  is  exposed.  The  gland  mass 
must  be  enucleated  by  blunt  dissection  with  the  finger  or  with  the 
blunt-pointed,  curved  scissors,  working  all  the  time  very  c'ose  to 
the  surface  of  the  gland  mass,  and  occasionally  snipping  connective- 
tissue  strands  that  show  when  traction  is  made  on  the  gland  mass. 
Traction  is  made  on  the. mass  and  the  adjacent  structures  slowly 
and  deliberately  peeled  away  from  it.  During  the  course  of  the 
enucleation  some  branches  of  the  transverse  cervical  and  the  sub- 
scapular veins  will  be  seen.    These  may  be  pushed  aside  or  they  may 


OPERATIONS  UPON  THE  NECK. 


243 


Fig.  140. —Incisions  for  Gaining  Access  to  the  Various  Triangles  of  the  Neck. 
C,  cricoid  cartilage;  U.,  hyoid  bone;  I.T.,  isthmus  of  the  thyroid  gland;  T., 
thyroid  cartilage.  1-2,  for  glands  situated  along  the  anterior  border  of  the 
sterno-mastoid  muscle  and  along  the  course  of  the  internal  jugular  vein;  1-3, 
for  opening  up  the  submaxillary  triangle;  2,  for  ligation  of  the  common  caro- 
tid artery,  etc. ;  4,  for  glands  along  the  posterior  border  of  the  sterno-mastoid 
muscle;  4-5,  for  glands  situated  in  the  subclavian  triangle;  5,  for  ligation  of  the 
subclavian  artery. 


344  NECK  AND  TONGUE. 

be  divided  or  torn  and  will  require  ligation.  After  the  mass  has 
been  removed  there  will  be  exposed,  in  the  bottom  of  the  rather  deep 
wound,  the  cords  of  the  brachial  plexus,  the  subclavian  artery  resting 
upon  the  first  rib,  and  the  dome  of  the  pleura.  The  phrenic  nerve 
passes  obliquely  across  the  front  of  the  tendon  of  the  scalenus  anticus 
into  the  thorax.  Usually  there  is  little  danger  of  injuring  this  struc- 
ture. All  hemorrhage  must  be  controlled  before  the  incision  is  closed. 
The  incision  is  closed  in  part  with  several  interrupted  sutures  and 
a  strip  of  gauze  left  for  drainage. 

OPERATIONS  UPON  THE  TRACHEA  AND  LARYNX. 

Tracheotomy  means  opening  into  the  air-passage  either  as  an 
emergency  operation  for  relief  when  obstruction  exists  or  as  a  prelimi- 
nary step  to  other  operations;  for  example,  extirpation  of  the  larynx, 
amputation  of  the  tongue,  etc.  In  1869,  as  a  preliminary  to  excision 
of  the  jaw,  Nussbaumi  performed  a  tracheotomy  and  tamponed  the 
pharynx  with  a  compress  to  prevent  blood  from  entering  the  larynx 
during  the  operation,  the  anaasthetic  being  administered  through  the 
tracheotomy  tube. 

Tampon  of  the  Trachea. — Trendelenburg  uses  a  tracheotomy 
tube  which  is  su:rrounded  by  a  thin,  balloon-like  structure  provided 
with  a  cannula  so  that  it  may  be  inflated  after  it  has  been  introduced 
into  the  trachea,  in  this  way  plugging  the  trachea  and  preventing  the 
entrance  of  blood,  etc.  The  anaesthetic  is  administered  through  the 
tracheotomy  tube,  to  which  a  long  rubber  tube  provided  with  a  fun- 
nel is  attached;  in  the  bottom  of  the  funnel  there  is  a  wad  of  cotton 
upon  which  the  anaesthetic  is  dropped.  The  tracheotomy  tube  and 
tampon  may  be  allowed  to  remain  in  the  trachea  for  seven  or  eight 
days  after  the  operation. 

The  Site  of  Operation. — ^The  opening  into  the  air-passage 
may  be  made : — 

1.  Through  the  trachea  above  the  isthmus  of  the  thyroid  gland 
.(high  tracheotomy).  This  is  the  preferable  operation  and  usually 
includes,  in  addition,  division  of  the  cricoid  cartilage  (crico-trache- 
otomy). 

2.  Through  that  part  of  the  trachea  which  is  covered  by  the 
isthmus  of  the  thyroid  gland  (median  tracheotomy). 

3.  Through  the  trachea  below  the  isthmus  of  the  thyroid  gland 
(low  tracheotomy).  This  operation  is  rather  less  preferable,  because 
at  this  level  the  trachea  lies  deeper — farther  away  from  the  surface, 


OPERATIONS  UPON  THE  TRACHEA  AND  LARYNX.  245 

and,  besides,  one  may  meet  tlie  inferior  thyroid  veins  or  some  of 
their  branches  or  there  may  be  an  arteria  thyroidea  ima  present. 
This  is  the  site  usually  selected  for  a  preliminary  tracheotomy  in 
conjunction  with  operations  upon  the  larynx;  for  example,  extir]Da- 
tion  of  the  larynx. 

4.  Through  the  crico-thyroid  membrane.  This  is  really  a  laryn- 
gotomy,  but  it  is  well  to  include  it  with  the  tracheotomies. 

High  Tracheotomy  (Crico-tracheotomy). — This  is  the  op- 
eration usually  performed,  and  has  the  advantage  that  no  vessels  of 
moment  are  met  with;  and  that  this  part  of  the  air-tube  is  located 
quite  superficially,  near  the  surface. 


Fig.  141.— Tracheotomy   Tube.  Fig.    142.— Trendelenburg    Tampon    Can- 

nula. T,  tube  to  inflate  balloon.  Anaes- 
thetic is  given  through  a  long  tube  and 
funnel   attached   to   tracheotomy   tube. 

The  patient  lies  upon  the  back  with  the  shoulders  raised  and 
the  head  thrown  back.  If  the  symptoms  of  sufi'ocation  are  urgent, 
one  may  dispense  with  an  anaesthetic  or  may  give  simply  a  few  whiffs 
of  chloroform.     The  operation  may  be  done  under  cocain  antesthesia. 

By  palpation,  the  ring-like  cricoid  cartilage,  which  is  the  best 
landmark,  is  readily  located.  In  men  the  prominent  thyroid  carti- 
lage may  be  felt  and  seen  as  Adam's  apple,  1)ut  in  women  and  chil- 
dren this  is  not  prominent  and  is  not,  therefore,  a  good  guide. 

An  incision  is  made  through  the  skin  and  subcutaneous  fat  from 
the  lower  border  of  the  thyroid  cartilage — just  alcove  the  cricoid — 
do-wTiward,  in  the  middle  line  of  the  neck,  for  a  distance  of  one  and 
one-half  inches.  In  making  this  skin  incision  some  small  tributaries 
of  the  anterior  jugular  vein  may  be  encountered ;  to  these  clamps  are 
applied  and  the  skin  retracted,  exposing  thus  the  deep  cervical  fascia 
which  unites  the  edges  of  the  stemo-hyoid  muscles  of  either  side 
with  each  other.     This  layer  of  fascia  is  incised  along  the  middle 


246  NECK  AND  TONGUE. 

line,  corresponding  to  the  incision  in  the  integument.  The  edges  of 
the  wound  being  now  retracted;,  there  are  exposed,  above  the  cricoid 
cartilage  and  just  below  the  cricoid,  lying  transversely  across  the 
front  of  the  trachea,  the  isthmus  of  the  thyroid  gland.  The  isthmus 
of  the  thyroid  gland  is  located  about  one-half  inch  below  the  cricoid 
cartilage  to  which  it  is  connected  by  a  process  of  the  deep  cervical 
fascia.  This  slip  of  fascia  covers  or  conceals  the  upper  two  rings  of 
the  trachea;  so  that,  in  order  to  expose  these,  it  is  necessary  to  pick 
up  this  band  and  snip  it  transversely,  after  which  the  isthmus  may 
be  drawn  downward  and  the  upper  rings  of  the  trachea  exposed  to 
view. 

The  next  step  is  to  enter  the  air-passage,  but  before  doing  this 
all  bleeding  points  should  be  clamped.  At  times,  during  the  operation, 
the  larynx  moves  violently  up  and  down  in  forced  efforts  at  respira- 
tion, and  in  order  to  steady  it  a  tenaculum  must  be  employed.  This 
is  introduced  into  the  larynx  above  the  cricoid  cartilage,  piercing 
the  crico-thyroid  membrane,  and  hooks  the  cricoid  cartilage  firmly 
upon  its  posterior  aspect  a  little  to  the  right  of  the  middle  line.  The 
operator  holds  this  tenaculum  with  the  left  hand,  thus  steadying  the 
larynx  and  trachea,  and,  with  a  sharp-pointed  knife  held  short  in 
the  right  hand,  the  cricoid  and  one  or  two  upper  rings  of  the  trachea 
are  cut  deliberately  from  above  downward.  One  guards  the  knife 
blade  in  order  to  avoid  injuring  or  perforating  the  posterior  wall 
of  the  trachea.  Having  made  an  opening  in  the  air-tube  about  one- 
half  inch  long  and  still  retaining  the  tenaculum  which  was  hooked 
into  the  cricoid  to  the  right  of  the  middle  line,  a  second  tenaculum 
is  now  hooked  into  the  other  side  of  the  cricoid,  to  the  left  of  the 
middle  line,  and  the  incision  in  the  air-passage  thus  held  open  while 
the  tube  is  being  introduced. 

Occasionally  the  thyroid  gland  has  a  well-marked  middle  lobe 
occupying  the  site  of  the  isthmus  and  ascending  upon  the  front  of 
the  cricoid.  This  extra  lobe  is  seldom  present,  but,  when  it  is,  it 
must  be  dislocated  downward  in  order  to  expose  the  cricoid  and  the 
upper  part  of  the  trachea.  Usually  it  is  not  necessary  to  apply  any 
ligatures  as  the  cut  vessels  cease  bleeding  after  a  few  minutes'  ap- 
plication of  the  artery  forceps;  still,  if  any  spurting  vessels  are  met, 
they  should  be  ligated.  The  edges  of  the  skin  may  be  brought  to- 
gether with  two  interrupted  catgut  sutures,  one  above  and  the  other 
below  the  tube. 

The  tube  is  held  in  place  by  a  tape  tied  aroimd  the  neck  and 


OPERATIONS  UPON  THE  TRACHEA  AND  LARYNX.      247 

the  wound  dressed  with  gauze  packed  loosely  into  the  wound  and 
about  the  tube. 

Low  TuACiiEOTOMY. — ^Tlie  opening  is  made  into  the  trachea 
below  the  isthmus  of  the  thyroid  gland.  This  is  not  usually  the  site 
of  choice,  although  it  is  at  times  indicated.  This  part  of  the  trachea 
lies  farther  away  from  the  surface,  deeper,  and  one  may  meet  the 
inferior  thyroid  veins,  which  descend  in  front  of  the  trachea,  although 
they  usually  lie  well  to  either  side  of  the  middle  line,  thus  leaving 
the  line  of  incision  free.  At  times  there  is  an  arteria  thyroidea  inia 
!  ascending  in  front  of  this  part  of  the  trachea:  a  rather  unusual 
condition. 

The  incision,  in  the  middle  line  of  the  neck,  commences  above 
at  a  point  just  below  the  cricoid  cartilage,  and  is  continued  down- 
ward toward  the  sternimi,  for  a  distance  of  one  and  one-half  to  two 
inches.  The  incision  penetrates  first  through  the  skin  and  fat,  and 
is  then  continued  deeper  through  the  deep  cervical  fascia,  exposing 
the  front  of  the  trachea.  After  the  trachea  has  been  exposed  all 
bleeding  points  must  be  clamped;  usually  the  hemorrhage  is  only 
venous  and  ceases  after  the  artery  forceps  have  been  applied  for  a 
few  minutes.  The  operator  is  now  ready  to  make  the  opening  in 
the  trachea,  which  should  be  placed  below  the  level  of  the  isthmus 
of  the  thyroid  gland;  the  isthmus  may  be  drawn  upward  toward 
the  cricoid  cartilage  in  order  to  give  more  room.  All  bleeding  should 
be  controlled  before  the  trachea  is  opened. 

Before  making  the  incision  in  the  trachea  a  tenaculum  is  intro- 
duced into  the  trachea,  just  below  the  isthmus  of  the  thyroid  gland 
and  a  little  to  one  side  of  the  middle  line,  to  steady  the  trachea,  and 
with  a  sharp-pointed  knife,  held  short  by  the  blade,  an  incision  is 
made  into  the  trachea  from  below  upward,  cutting  two  or  three 
rings.  Still  steadying  the  trachea  with  the  first  tenaculum,  a  second 
tenaculum  is  introduced  into  the  incision  in  the  trachea,  and  while 
it  is  thus  held  open  the  tube  is  introduced.  The  tenacula  are  not 
withdrawn  until  the  tube  is  in  the  trachea. 

Any  spurting  vessels  or  large  veins  may  be  ligated,  and  one  or 
two  stitches  may  be  taken  in  the  skin  wound.  The  left  innominate 
vein  is  not  in  danger  if,  in  incising  the  trachea,  the  laiife  is  not 
carried  below  the  level  of  the  sternum. 

Median  Tracheotomy. — The  opening  into  the  trachea  is  made 
heneath  the  isthmus  of  the  thyroid  gland,  which  is  divided  in  order 
to   expose   this   part   of   the   trachea. 


248  NECK  AND  TONGUE. 

The  incision  passes  through  the  skin  and  fat  and  reaches  from 
the  cricoid  cartilage  downward,  in  the  middle  line  of  the  neck,  for 
a  distance  of  one  and  one-half  to  two  inches.  The  incision  is  then 
carried  deeper  through  the  deep  fascia,  between  the  edges  of  the 
stemo-hyoid  muscle,  when  the  isthmus  of  the  th5rroid  gland  is  ex- 
posed. The  isthmus  is  divided  and  the  trachea  recognized.  In 
dividing  the  isthmus  we  cut  several  venous  branches  which  bleed 
and  must  be  clamped.  The  bleeding  should  be  controlled  before  the 
trachea  is  opened.  Bleeding  points  may  be  clamped  and  their  liga- 
tion postponed  until  after  the  tu.be  has  been  introduced  into  the 
trachea  if  time  is  limited.  The  trachea  is  steadied  with  a  tenaculum 
and  incised,  and  the  tube  introduced,  as  in  the  foregoing  operation. 

Transverse  Laryngotomy. — This  is  an  emergency  operation 
and  may  be  rapidly  performed.  The  windpipe  is  opened  after  locating 
the  cricoid  cartilage  and  using  this  as  a  guide,  by  cutting  transversely 
through  the  skin  and  crio-thyroid  membrane :  i.e.^  between  the  upper 
border  of  the  cricoid  and  the  lower  border  of  the  thyroid  cartilage. 
There  is  some  probability  of  wounding  the  crico-thyroid  artery,  a 
small  braiich,  yet  this  is  not  very  likely  as  the  incision  is  made 
transversely:    parallel  with  the  course  of  the  artery. 

Thyrotomy. — ^Division  of  the  thyroid  cartilage  may  be  either 
incomplete  or  complete. 

Incomplete  Thyrotomy. — ^The  incision  is  placed  in  the  middle 
line  of  the  neck  and  commences,  above,  at  a  point  just  below  the 
upper  border  of  the  thyroid  cartilage,  and  is  continued  downward 
to  a  point  just  below  the  cricoid  cartilage;  it  is  about  one  and  one- 
half  to  two  inches  long  and  reaches  through  the  skin  and  deep 
fascia,  exposing  the  cricoid  and  thyroid  cartilages.  The  edges  of  the 
wound  are  retracted  and  the  crico-thyroid  membrane  incised,  thus 
entering  the  larynx.  In  incising  the  crico-thyroid  membrane  the 
crico-thyroid  branches  may  be  cut;  these  are  small  branches,  but 
they  should  be  clamped  if  they  bleed,  as  even  a  small  quantity  of 
'blood  sucked  into  the  wind-pipe  may  seriously  embarrass  respiration. 
We  then  proceed  to  enlarge  the  opening  into  the  larynx  by  dividing' 
the  cricoid  cartilage  and  the  lower  part  of  the  thyroid  cartilage, 
to  an  extent  sufficient  to  permit  the  extraction  of  foreign  bodies,  etc. 
One  should  avoid,  if  possible,  incising  the  thyroid  cartilage  beyond 
the  level  at  which  the  true  vocal  cords  are  attached. 

If  this  operation  is  done  for  the  removal  of  a  foreign  body,  one 
may  close  the  opening  in  the  larynx  and  omit  the  introduction  of  a 


OPERATIONS  UPON  THE  TRACHEA  AND  LARYNX.  249 

tube;  still  it  is  probably  not  unwise  to  insert  tbe  tube  and  leave  it 
for  a  few  days  in  all  cases,  because,  as  a  result  of  the  operation,  there 
may  be  some  oedema  of  the  glottis  caused. 

Complete  Thyrotomy  consists  of  a  median  section  through  the 
thyroid  cartilage.  This  operation  is  done  for  the  purpose  of  ex- 
ploring the  interior  of  the  larj^nx  and  for  the  removal  of  foreign 
bodies,  growths,  etc. 

During  the  operation  the  trachea  must  be  kept  clear  of  blood. 
The  operation  should  be  performed  with  the  patient  in  the  Eose 
position  unless  a  tampon  cannula  is  used,  when  the  patient  may  be 
placed  in  the  usual  tracheotomy  position  with  the  shoulders  raised 
and  the  head  thrown  back.  The  tampon  cannula  may  be  introduced 
through  a  preliminary  high  tracheotomy  done  at  the  same  sitting, 
previous  to  opening  the  larynx,  or  else  the  cannula  may  be  inserted 
through  the  incision  that  is  made  in  the  larynx  and  which  may  be 
prolonged  downward,  through  the  cricoid  and  upper  rings  of  the 
trachea  for  this  purpose.  Instead  of  a  high  tracheotomy,  a  prelimi- 
nary low  tracheotomy  may  be  performed  and  the  tampon  cannula 
introduced  at  this  point. 

The  incision  is  placed  in  the  middle  line  of  the  neck,  reaching 
from  the  hyoid  bone,  above,  to  a  point  below  the  level  of  the  cricoid 
cartilage.  The  incision  extends  through  the  skin  and  deep  fascia 
and  exposes  the  thyroid  cartilage. 

The  next  step  is  to  open  the  lar}'nx.  The  point  of  the  knife 
is  introduced  through  the  crico-thyroid  membrane  between  the  cricoid 
and  the  lower  border  of  the  thyroid  cartilage.  In  doing  this  the  crico- 
thyroid branch  may  be  cut  and  should  be  clamped  and  tied.  Then, 
with  a  curved  probe-pointed  knife  which  is  introduced  into  the  larynx 
and  passed  upward  between  and  beyond  the  vocal  cords  the  thyroid 
cartilage  is  split  into  its  two  halves  from  within  outward,  in  the  middle 
line,  throughout  its  entire  length  up  to  or  into  the  thyro-hyoid 
membrane.  The  thyroid  cartilage  may  also  be  divided  from  without 
inward.  At  times  the  thyroid  cartilage  is  ossified,  and  it  will  be 
necessary  to  use  a  strong  scissors  in  order  to  accomplish  its  division. 

After  the  thyroid  cartilage  has  been  split  its  edges  are  held  apart 
with  sharp  retractors  or  tenacula,  and  the  interior  of  the  lan'nx 
may  then  be  freely  explored.  We  may,  in  addition,  divide  the  cricoid 
cartilage  and  the  upper  rings  of  the  trachea  if  this  has  not  already 
been  done,  or  if  more  room  is  required,  or  in  order  to  introduce  a 
tampon  cannula. 


250  NECK  AND  TONGUE. 

In  cutting  into  the  thyro-hyoid  membrane  one  should  avoid  the 
superior  laryngeal  vessels  and  nerve,  which  pierce  this  membrane 
upon  either  side  to  enter  and  supply  the  larynx. 

It  may  not  be  necessary  to  suture  the  two  halves  of  the  thyroid 
cartilages,  as  these  often  ada]3t  themselves  very  well  without  suture, 
especially  if  the  cricoid  cartilage  has  not  been  divided.  It  is  jDrobably 
wise,  however,  in  all  cases,  to  introduce  two  or  three  chromicized 
catgut  sutures  through  the  perichondriimi  to  hold  the  edges  of  the 
two  halves  of  the  thyroid  cartilage  in  contact  or  one  silver  wire  suture 
may  be  passed  through  each  edge  of  the  cartilage.  The  incision  in 
the  skin  may  be  partly  closed  with  catgut  sutures. 

The  tampon  cannula,  if  used,  may  be  left  in  place  for  a  few 
days  if  it  is  well  borne,  as  it  prevents  the  entrance  of  blood  and  dis- 
charges into  the  trachea  and  lungs. 

Laryngectomy  (Extirpation  of  the  Larynx). — This  operation 
should  be  preceded  by  a  low  tracheotoni}'-,  which  may  be  done  a  week 
or  more  in  advance  of  the  major  operation  in  order  to  accustom  the 
patient  to  the  presence  of  the  tube  and  to  bring  about  fixation  of  the 
trachea  to  the  skin,  etc.,  of  the  neck. 

If  the  preliminary  tracheotomy  has  not  been  done,  the  operation 
should  be  performed  with  the  patient  in  the  Eose  position,  or,  if  the 
operation  is  done  with  the  patient  in  the  customary  tracheotomy 
position,  it  will  be  necessary,  as  soon  as  the  larynx  has  been  isolated 
and  all  the  vessels  that  supply  it  ligated,  to  cut  the  larynx  away  from 
the  trachea  below  and  then,  at  once,  introduce  the  tampon  cannula 
into  the  upper  end  of  the  trachea.  The  preliminary  tracheotomy, 
with  the  introduction  of  the  tampon  cannula,  is  probably  the  most 
preferable  plan. 

The  incision  is  made  in  the  middle  line  from  the  hyoid  bone  to 
a  point  below  the  cricoid  cartilage;  to  this  incision  a  second  trans- 
verse incision  may  be  added  which  extends  outward,  parallel-  with 
the  hyoid  bone,  between  the  hyoid  bone  and  upper  border  of  the 
thyroid  cartilage,  as  far  as  the  anterior  border  of  the  sterno-mastoid 
muscle  of  each  side,  thus  making  a  T-shaped  incision.  This  latter" 
supplementary  incision  is  especially  advantageous  if  the  lymphatic 
glands,  etc.,  are  involved  in  the  pathological  process.  The  incision 
extends  through  the  skin  and  subcutaneous  fat  and  deep  cervical 
fascia,  and  exposes  the  thyroid  cartilage. 

The  edges  of  the  sterno-hyoid  muscles  are  next  recognized  and 
the  muscles   of   either   side   divided   transversely   either  partially   or 


OPERATIONS  UPON  THE  TRACHEA  AND  LARYNX.      251 

completel3^  The  parts  being  now  retracted,  we  expose  the  sterno- 
thyroid and  thyro-hyoid  muscles,  which  are  attached  npon  either  side 
of  the  thyroid  cartilage.  The  lateral  lobes  of  the  thyroid  gland  reach 
well  upward  npon  the  sides  of  the  thyroid  cartilage  underneath  the 
sterno-thyroid  muscles. 

We  now  begin  the  isolation  of  the  larynx,  separating  all  the  soft 
parts  either  Avith  an  elevator  or  with  the  knife,  the  edge  of  the 
instrument  working  close  to  the  surface  of  the  thyroid  cartilage.  If 
the  elevator  is  used,  this  is  pushed  under  the  thyro-hyoid  muscle,  be- 
\tween  it  and  the  thyroid  cartilage,  and  the  muscle  separated  from 
the  side  of  the  thyroid  cartilage,  detaching  the  sterno-thyroid  at  the 
same  time;  the  separation  of  these  muscles  may  be  accomplished  in 
part  with  the  loiife.  These  two  muscles  are  really  one  and  the  same 
continuous  muscle;  so  that,  after  they  have  been  detached  from  the 
thyroid  cartilage  they  hang  together  as  one  continuous  flat  band. 
Instead  of  detaching  these  muscles  as  described  they  may  be  simply 
cut  away  from  the  sides  of  the  thyroid  cartilage  with  the  knife.  The 
soft  parts  are  then  retracted  and  a  tenaculum  is  hooked  into  the 
side  of  the  thyroid  cartilage,  and  with  this  the  larjaix  is  drawn  for- 
ward and  to  one  side,  so  that  we  are  enabled  to  reach  the  superior 
laryngeal  artery  and  its  accompanying  nervous  branch,  as  they  pierce 
the  side  of  the  thyro-hyoid  membrane  to  enter  the  larjmx;  the  vessel 
is  tied  double  and  cut.  The  lateral  lobe  of  the  thyroid  gland,  which 
lies  upon  the  side  of  the  larynx  (in  the  natural  relation  of  the  parts 
being  covered  by  the  sterno-thyroid  muscle),  is  readily  separated  from 
the  side  of  the  larynx  with  the  elevator  or  the  finger.  At  this  stage 
of  the  operation  the  superior  thyroid  artery,  which  ramifies  upon 
the  upper  front  surface  of  the  thyroid  gland,  is  usually  met  with. 
This  vessel  need  not  be  cut.  The  thyroid  isthmus  is  also  liberated 
from  its  attachment  to  the  cricoid  cartilage  and  pushed  downward 
out  of  the  way. 

The  crico-thyroid  branch  of  the  superior  thyroid,  which  runs 
forward  and  inward  transversely  across  the  crico-thyroid  membrane, 
may  be  cut  and  should  be  clamped  and  tied.  There  is  also  an  in- 
ferior laryngeal  branch,  from  the  inferior  thyroid,  which  accompanies 
the  inferior  laryngeal  nerve  into  the  larynx;  it  enters  the  lower 
back  part  of  the  larynx,  behind  the  articulation  between  the  cricoid 
and  thyroid  cartilages,  beneath  the  lateral  lobe  of  the  thyroid  gland; 
this  branch  may  be  cut  and  should  be  tied.  The  small  transverse 
branch,  from  the  superior  thyroid,  which  nins  transversely  inward 


352  NECK  AND  TONGUE. 

across  the  thyro-hyoid  membrane,  below  the  hyoid  bone,  to  anastomose 
with  its  fellow  of  the  opposite  side,  is  also  cut  and  tied.  The  lar3rnx 
is  drawn  toward  the  opposite  side  and  the  above-described  procedures 
are  repeated  upon  the  other,  the  remaining,  side. 

The  isolation  of  the  larynx  is  continued.  The  soft  parts  are 
strongly  retracted  to  one  side  and  with  a  sharp  hook  or  volsella  the 
larjTix  is  drawn  to  the  opposite  side;  then,  with  the  knife,  the  in- 
ferior constrictor  of  the  phar5^nx  is  separated  from  the  side  of  the 
thyroid  cartilage.  This  muscle  is  attached  upon  the  side  of  the 
thyroid  cartilage  close  to  its  posterior  border  which  may  be  readily 
felt  by  the  fingers  in  the  wound.  This  muscle  is  separated  from  the 
cricoid  cartilage  also.  Care  should  be  exercised  to  work  close  to  the 
surface  of  the  cartilage  in  separating  this  muscle  so  as  to  avoid 
opening  into  the  pharynx,  and  also  to  avoid  division  again  of  the 
vessels  that  have  already  been  divided  and  tied.  The  parts  are  then 
separated  in  a  similar  manner  upon  the  other  side  of  the  larynx  and 
we  are  ready  for  the  final  step  of  this  part  of  the  operation :  the 
separation  of  the  larynx  from  the  hyoid  bone  above,  from  the  ante- 
rior wall  of  the  pharynx  behind,  and  from  the  trachea  below. 

The  knife  is  introduced  through  the  thyro-hyoid  membrane  be- 
tween the  thyroid  cartilage  and  the  hyoid  bone,  and  this  membrane 
is  cut  in  a  direction  outward  and  backward,  at  the  same  time  draw- 
ing the  side  of  the  larynx  forward  with  a  sharp  hook  or  volsella. 
In  performing  this  step  of  the  operation  we  should  avoid  again  cut- 
ting the  superior  laryngeal  artery  upon  the  proximal  side  of  its  liga- 
ture if  it  has  already  been  divided  and  tied.  The  other  half  of  the 
thyro-hyoid  membrane  is  then  cut  in  a  similar  manner.  If  it  is 
desired  to  excise  the  epiglottis  also,  and  this  is  usually  wise,  a  probe- 
pointed  knife  may  be  introduced  through  the  incision  in  the  thyro- 
hyoid membrane,  between  the  upper  border  of  thyroid  cartilage  and 
the  hyoid  bone,  in  a  direction  upward  and  backward;  so  that,  as  the 
cut  is  made,  the  blade  of  the  knife  passes  between  the  base  of  the 
tongue  and  the  epiglottis.  The  finger  in  the  mouth  may  serve  to 
guide  the  knife.  If  the  epiglottis  is  to  be  left,  we  cut  directly  back- 
ward between  the  upper  border  of  the  thyroid  cartilage  and  the  hyoid 
bone,  thus  leaving  the  epiglottis  attached  to  the  posterior  aspect  of 
the  hyoid  bone  and  to  the  root  of  the  tongue.  The  front  of  the 
larynx  is  then  seized  with  a  sharp  hook  or  volsella  forceps  and  drawn 
directly  forward;  so  that  its  posterior  wall,  composed  of  the  broad 
posterior  part  of  the  cricoid  cartilage,  may  be  separated  from  the 


OPERATIONS  UPON  THE  TRACHEA  AND  LARYNX.      253 

anterior  wall  of  the  pharynx;  the  anterior  wall  of  the  pharynx  is 
very  thin,  consisting  practically  only  of  a  layer  of  mucous  membrane. 
If  the  growth  involves  the  anterior  wall  of  the  pharynx,  this  part  may 
be  excised  together  with  the  larynx.  If  the  pharynx  has  not  yet  be- 
come involved  in  the  disease,  the  separation  of  the  larynx  from  the 
pharynx  will  not  be  found  to  be  difficult  of  accomplishment. 

After  the  separation  of  the  larynx  from  the  pharynx  has  been 
completed  to  a  point  below  the  level  of  the  cricoid  cartilage,  the 
lar}-nx  is  cut  away  from  the  trachea,  from  behind  forward,  below  the 
level  of  the  cricoid  cartilage.  In  thus  severing  the  larynx  from 
the  trachea  the  inferior  laryngeal  arteries  and  nerves  are  cut,  and, 
if  the  vessels  have  not  already  been  tied,  they  should  be  secured  as 
they  spurt.     Thus  the  extirpation  is  complete. 

Instead  of  operating  as  described  above,  we  may,  after  freeing 
the  larynx  upon  the  sides,  etc.,  complete  the  operation  by  cutting 
the  larjmx  away  from  the  trachea  below  the  level  of  the  cricoid 
cartilage,  packing  the  stump  of  the  trachea  at  once  with  a  pad  to 
prevent  the  entrance  of  the  b^ood  (a  preliminarv^  tracheotomy  having 
been  done) ;  and  then,  drawing  the  laiynx  fonvard  with  a  sharp 
hook  or  volsella,  this  is  separated  from  the  anterior  wall  of  the  pharynx 
from  below  upward;  and,  as  the  final  step  of  the  operation,  the 
larynx  is  cut  away  from  its  attachment  to  the  hyoid  bone  by  carry- 
ing the  knife  through  the  thyro-hyoid  membrane. 

The  superior  laryngeal  arteries,  that  enter  the  larynx  upon  the 
sides,  are  best  secured  before  beginning  the  actual  isolation  of  the 
larynx,  but  they  may  be  again  divided  accidentally  during  the  final 
steps  of  the  operation,  and  in  this  case  should  be  again  clamped  and 
tied;  other  vessels  may  be  secured  as  they  are  encountered  during 
the  course  of  the  operation.  The  wound  is  best  left  open  in  part. 
If  the  accessor}'  lateral  skin  incisions  have  been  made,  and  the  sterno- 
mastoids  have  been  di\ided,  these  parts  may  be  brought  together 
with  sutures.  The  opening  in  the  pharynx  should  be  closed  as  nearly 
completely  as  possible  with  interrupted  silk  sutures,  their  ends  being 
left  long  to  facilitate  their  removal  later.  It  may  be  possible  in  some 
cases  to  close  off  the  pharyngeal  space  from  the  wound  completely 
by  uniting  the  upper  cut  edge  of  the  pharynx  to  the  soft  parts  which 
are  attached  to  tissues  below  the  hyoid  bone.  This  is  done  with  a 
sufficient  number  of  interrupted  silk  sutures  placed  fairly  close  to- 
gether, and  is  a  great  advantage,  as  it  veiy  considerably  diminishes 
the  likelihood  of  infection. 


254  NECK  AND  TONGUE. 

It  is  necessary  to  arrange  good  drainage  with  the  head  low,  so 
as  to  avoid  the  entrance  of  wound  secretions  into  the  trachea.  It 
is  well  to  leave  the  tampon  cannula  in  the  trachea  for  a  few  days  if 
it  has  been  used  during  the  operation.  The  wound  should  be  prop- 
erly packed  and  the  dressings  changed  at  rather  frequent  intervals. 

After  the  operation  the  patient  is  fed  per  rectum  or  else  through 
a  tube  introduced  into  the  stomach  either  through  the  mouth  or 
through  the  nose.  If  a  tracheotomy  has  not  preceded  the  laryngectomy 
by  a  week  or  more,  the  stump  of  the  trachea  should  be  sutured  to  the 
skin  in  order  to  prevent  too  great  retraction  of  the  trachea.  In  cases 
where  the  disease  has  not  spread  beyond  the  larynx,  the  operation 
is  comparatively  easy  and  not  accompanied  by  much  hemorrhage. 

Before  proceeding  with  the  radical  operation  the  larj^nx  may 
be  split  in  the  middle  line  for  the  purpose  of  exploration.  It  may 
be  that  in  some  early  cases  the  removal  of  one-half  of  the  larynx 
will  suffice. 

Extirpation  of  Half  of  the  Larynx. — This  operation  is  quite 
analogous  to  the  one  described  in  the  preceding  paragraphs,  and  may 
be  practiced  in  those  cases  where  the  disease  is  still  limited  to  one 
side  of  the  lar3mx. 

The  larynx  is  first  split  in  the  middle  line,  without  injuring  the 
vocal  cords,  and  then,  if  the  condition  found  upon  investigation  war- 
rants, the  operation  of  extirpation  of  one-half  of  the  lar3'nx  may  be 
undertaken. 

The  advantages  of  partial  removal  of  the  larynx  in  appropriate 
cases  are  undoubted.  It  is  a  much  less  difficult  and  dangerous  pro- 
cedure and  there  is  no  gTcater  likelihood  of  recurrence  after  this  less 
radical  operation  when  the  disease  is  still  confined  to  one  side  of  the 
larynx.  The  voice  may  be  almost  perfectly  retained  and  the  ability 
to  swallow  food  is  quickly  regained. 

OPERATIONS  UPON  THE  THYROID  GLAND. 

These  may  consist  of  partial  extirpation,  enucleation,  ligation  of 
blood-vessels,  etc.  Operation  is  indicated  as  soon  as  the  tumor  begins 
to  interfere  seriously  with  respiration  or  shows  inflammatory  changes 
or  a  tendency  to  malignant  degeneration.  Tumors  that  grow  down- 
ward into  the  root  of  the  neck  or  mediastinum,  causing  pressure  upon 
the  trachea,  should  be  operated  upon  early.  Operation  should  be 
undertaken  for  exophthalmic  goitre  just  as  soon  as  symptoms  of 
Basedow's  disease  begin  to  make  their  appearance.     In  those  cases 


OPERATIONS  UPON  THE  THYROID  GLAND.  255 

of  exophthalmic  goitre  that  show  very  marked  symptoms  of  thyroid- 
ism,  marked  exophthahuos,  very  rapid,  irregular  pulse,  dyspnoea, 
tremor,  sweating,  marked  nervous  irritability,  sleeplessness,  etc.,  it  is 
desirable  to  do  the  operation  in  several  stages;  to  first  ligate  the  su- 
perior thyroid  arteries  and  veins,  on  one  or  both  sides,  usually  on  both, 
leaving  the  extirpation  of  the  gland  until  later — until  the  exaggerated 
symptoms  of  excessive  thyroidism  have  abated — ^usually  for  several 
weeks.  In  cases  where  there  is  already  degeneration  of  the  heart 
muscle  and  of  other  essential  organs,  operation  will  almost  certainly 
result  fatally  and  is  counterindicated.  The  operation  may  be  per- 
formed under  local  anaesthesia — regional  anaesthesia  method  (Kocher, 
Eeverdin,  Eoux)  or  a  general  anaesthetic  may  be  used.  If  a  general 
anaesthetic  is  employed  care  must  be  exercised  during  its  administra- 
tion, because  urgent  symptoms  due  to  interference  with  respiration 
may  arise.  Of  the  general  anesthetics,  ether  is  the  preferable  one. 
The  patient  should  be  placed  in  that  position  which  causes  the  least 
obstruction  to  breathing,  usually  with  the  shoulders  raised  upon  a 
sandbag  and  the  head  thrown  back.  It  is  often  of  distinct  advantage 
to  raise  the  upper  end  of  the  table  so  that  it  will  have  an  inclina- 
tion of  about  thirty  degrees.  With  the  patient  in  this  position  there 
is  much  less  venous  hemorrhage  and  much  less  interference  with 
respiration.  The  anaesthetic  can  be  given  with  the  Gwathmey  ap- 
paratus, using  the  foot-pump  to  force  the  air  through  the  bottle 
containing  the  anaesthetic,  and  with  the  Lumbard  nasal  tubes.  Thus 
the  anaesthetist  has  his  hands  free  and  is  able  to  hold  the  jaw  for- 
ward during  the  course  of  the  operation.  Many  operators  prefer  ether 
given  by  the  drop  method.  The  services  of  an  additional  assistant 
will  then  be  necessary  to  hold  the  jaw  forward. 

A  cloth  screen  suspended  from  two  uprights,  one  upon  either 
side  of  the  table,  may  be  dropped  down  so  as  to  shut  the  field  of 
operation  off  from  the  face — mouth  and  nose — of  the  patient.  This 
also  serves  to  exclude  the  antesthetist  from  the  field  of  operation. 
In  the  absence  of  the  screen  the  field  of  operation  can  be  walled 
off  from  the  mouth  by  placing  a  folded  towel  wrung  out  in  bichloride 
solution  across  the  neck  just  below  the  chin  and  just  above  the 
line  of  the  transverse  incision  in  the  neck. 

Partial  Extirpatiox. — As  a  rule,  but  one  lobe  is  extirpated. 
If  the  disease  involves  both  lobes,  then  one  entire  lobe,  the  larger, 
should  be  excised  and  the  other  lobe  only  in  part.  At  least  one- 
fourth  or  one-fifth  of  the  gland  substance  should  be  left.     The  en- 


256  NECK  AND  TONGUE. 

tire  organ  should  never  be  extirpated.  Even  if  the  whole  gland  is 
apparently  involved  a  portion^  at  least  one-fourth  or  one-fifth,  should 
be  permitted  to  remain. 

Two  essential  points  to  be  observed  in  operating  are  to  prevent 
severe  hemorrhage  during  the  course  of  the  operation  and-  to  avoid 
injuring  the  important  structures  that  are  situated  posterior  to  the 
thyroid  gland — the  recurrent  laryngeal  nerve  and  the  parathyroid 
bodies.  The  main  vessels  supplying  the  gland  are  ligated  early  in 
the  operation  and  finally,  in  extirpating  the  gland,  the  posterior  por- 
tion of  the  capsule  is  left  to  cover  over  and  insure  the  safety  of  the 
structures  that  lie  behind  it. 

A  transverse  incision  passing  across  the  front  of  the  neck  from 
the  edge  of  one  sterno-mastoid  muscle  to  the  edge  of  the  other  is 
made.  If  the  tumor  is  situated  low  down,  in  the  root  of  the  neck, 
the  incision  should  be  placed  low,  just  above  the  sternal  notch. 

Instead  of  the  incision  above  described  the  tumor  may  be  ex- 
posed through  a  right  angle  incision  which  commences  upon  the  side  of 
the  neck  behind  the  inner  edge  of  the  sterno-mastoid  musc"'e  at  the 
level  of  the  thyroid  cartilage;  from  that  point  the  incision  is  carried 
transversely  inward  to  the  middle  line  and  then  downward  as  far 
•as  the  sternal  notch.  This  incision  is  adapted  to  those  tumors  that 
are  situated  high  up  and  are  of  unusual  size  and  confined  strictly  to 
one  lobe.  The  incision  penetrates  through  the  skin,  fat,  and  platysma 
muscle,  and  exposes  the  sterno-hyoid  and  sterno-thyroid  muscles,  cov- 
ered by  the  deep  cervical  fascia,  and  the  sterno-mastoid  muscle.  Sev- 
eral subcutaneous  venous  branches  are  divided, — the  anterior  jugular 
and  communicating  branch  from  the  external  jugular;  these  should 
be  clamped  and  tied  or  they  may  be  ligated  doubly  before  they  are 
severed.     The  external  jugular  is  usually  not  cut. 

The  bluish  (slate-colored)  tumor  mass  may  now  be  seen  bulging 
beneath  the  depressor  muscles  of  the  hyoid  bone  (the  sterno-hyoid 
and  sterno-thyroid),  which  are  usually  found  displaced  more  or  less 
toward  that  side  of  the  neck  which  lodges  the  tumor.  The  tumor 
is  exposed  by  cutting  through  the  deep  cervical  fascia  between  the 
edges  of  the  sterno-hyoid  muscles.  This  incision  in  the  deep  fascia 
should  be  sufficiently  liberal.  If  more  room  is  required  the  fingers 
may  be  hooked  under  the  sterno-hyoid  and  sterno-thyroid  muscles 
and  these  may  be  divided  near  the  hyoid  bone.  It  may  be  necessary 
to  extend  the  incision  into  the  anterior  margin  of  the  sterno-mastoid. 
At  this  stage  the  operator  should  assure  himself  that  he  has  pen- 


OPERATIONS  UPON  THE  THYROID  GLAND.  257 

etrated  completely  through  the  loose  connective-tissue  envelope  riglit 
down  to  the  true  capsule  of  the  gland.  The  capsule  will  be  found 
considerably  thickened  in  cases  where  pathological  processes  affect 
the  gland. 

Sweeping  around  in  all  directions  with  the  lingers  close  to  the 
surface  of  the  tumor  mass,  the  effort  is  made  to  separate  it  and  de- 
liver it  jjartly  through  the  incision.  Connective-tissue  bands  that  hold 
the  tumor  and  resist  its  delivery  and  which  are  usually  vascular 
should  be  hooked  up  with  the  finger  or  ligature  carrier,  clamped 
double,  and  divided  with  the  scissors.  After  the  tumor  has  been 
thus  partly  detached  it  is  drawn  still  farther  out  of  the  incision  and 
the  operator  is  then  ready  for  the  next  step  of  the  procedure,  tho 
ligation  of  the  principal  vessels. 

While  the  mass  is  pulled  downward  and  toward  the  opposite  side 
the  superior  thyroid  vessels  are  sought  near  the  upper  pole  of  the 
tumor.  The  superior  thyroid  is  readily  found  just  after  its  origin 
from  the  external  carotid,  in  the  space  between  the  upper  border  of 
the  thyroid  cartilage  and  the  hyoid  bone.  It  is  accompanied  by  the 
superior  thyroid  vein,  which  may  be  included  in  the  same  ligature 
as  the  artery.  The  ligature  is  passed  with  the  blunt  carrier,  tied 
double,  and  the  vessels  divided  between  the  ligatures.  The  inferior 
thyroid  artery  is  found  deep  in  the  root  of  the  neck.  It  is  a  branch 
of  the  thyroid  axis.  Emerging  from  behind  the  common  carotid 
artery,  it  passes  inward  to  reach  the  middle  of  the  posterior  border 
of  the  lateral  lobe  of  the  gland,  crossing  the  inferior  recurrent  laryn- 
geal nen-e  in  its  course.  Firm  traction  must  be  made  upon  the 
tumor,  drawing  it  upward  and  over  toward  the  opposite  side  and 
the  skin  and  muscles  well  retracted.  With  the  fingers  in  the  wound 
the  pulsating  vessel  may  be  felt  as  it  passes  forward  across  the  side 
of  the  trachea  to  reach  the  gland.  The  prominent  tubercle  upon 
the  transverse  process  of  the  sixth  cervical  vertebra — ^the  tubercle  of 
ChassaigTiac — -is  a  good  guide.  About  on  a  level  with  or  just  below 
this  tubercle  the  artery  passes  across  the  front  of  the  recurrent  laryn- 
geal nerve,  which  ascends  in  the  recess  between  the  trachea  and 
oesophagus  to  enter  the  larynx.  The  artery  should  be  carefully  iso- 
lated, taking  pains  not  to  injure  the  nerve,  and  a  ligature  passed 
around  it  with  a  blunt  carrier  and  tied.  The  inferior  thyroid  veins 
are  picked  up  upon  the  carrier,  tied  double,  and  severed.  An  arteria 
thyroidea  ima  is  occasionally  encountered  ascending  toward  the  lower 
part  of  the  gland;  this  vessel  and  its  accompanying  veins  are  readily 


258  NECK  AND  TONGUE. 

recognized  and  should  be  ligated  double  and  divided  between  the 
ligatures. 

There  remains  now  to  make  the  section  through  the  isthmus. 
This  is  detached  and  squeezed  between  the  blades  of  a  heavj^  compres- 
sion forceps.  The  forceps  is  then  removed  and  the  isthmus  ligated, 
the  ligature  being  placed  so  as  to  secure  the  isthmus  at  the  site  of 
the  groove  made  with  the  compression  forceps.  If  a  third,  pyramidal, 
lobe  is  present,  it  should  also  be  detached  and  removed  together  with 
the  tumor  mass.  The  venous  branches  that  unite  the  veins  of  the 
two  lobes  of  the  gland  across  the  isthmus,  corresponding  to  its  upper 
and  lower  borders,  may  be  clamped  and  ligated  separately. 

The  blood-vessels  having  been  ligated  and  the  isthmus  divided, 
etc.,  there  now  remains,  in  order  to  complete  the  operation,  the  ex- 
tirpation of  that  portion  of  the  gland  which  is  to  be  removed.  It 
is  still  attached  to  the  side  of  the  trachea  and  larynx.  Care  must 
be  again  exercised,  in  separating  it  from  these  structures,  not  to 
dnjure  the  recurrent  laryngeal  nerve  and  the  parathyroid  bodies  that 
lie  posterior  to  the  capsule.  Injury  to  these  structures  is  best  avoided 
by  leaving  the  posterior  part  of  the  capsule  to  cover  and  protect  them. 
The  capsule  is  incised  along  the  outer,  posterior  border  of  the  lateral 
lobe  (tumor  mass),  and  the  mass  peeled  away  from  this  part  of 
the  capsule,  even  leaving  a  thin  layer  of  thyroid  tissue  covering  the 
surface  of  the  portion  of  capsule  that  is  left  behind. 

After  all  hemorrhage  has  been  controlled  the  wound  is  flushed 
out  with  salt  solution.  If  muscles  have  been  divided  their  ends 
should  be  reunited  by  suture?  A  cigarette  drain  which  is  allowed  to 
remain  for  twentj'-four  hours  is  introduced.  The  edges  of  the  skin 
are  brought  into  accurate  apposition  with  suture  except  below,  in 
the  middle  or  at  either  end,  where  the  drainage  strips  emerge. 

Enucleation. — This  method  of  treatment  is  adapted  to  those 
cases  that  present  isolated  diseased  masses  in  the  midst  of  apjaarently 
normal  gland  tissue. 

The  incision  and  subsequent  steps  of  this  procedure  until  the 
stage  is  reached  where  the  capsule  of  the  gland  is  exposed  are  the 
same  as  those  described  in  the  preceding  operation.  The  capsule 
is  incised  in  a  situation  where  it  is  fairly  free  from  blood-vessels. 
Vessels  that  are  divided  are  clamped  and  ligated.  Penetrating 
through  the  gland  substance  with  the  finger  the  mass  that  is  to  be 
enucleated  is  shelled  out;  if  any  additional  masses  are  to  be  felt 
these  are  also  enucleated  through  the   same  opening.     If  the  mass 


OPERATIONS  UPON  THE  THYROID  GLAND. 


259 


Fig.  143.— Thyroidectomy.  Tlie  enlarged  right  lobe  of  the  thyroid  gland  is 
delivered  out  of  the  incision.  The  superior  thyroid  artery  and  vein  have  been 
ligated  double  and  divided  between  the  ligatures.  The  inferior  thyroid  artery 
is  picked  up  upon  the  ligature  carrier.  C.C.,  common  carotid  artery;  I. J.,  in- 
ternal jugular  vein;  /.?'.,  inferior  thyroid  artery;  Ocs.,  OSsophagus;  R.L.y., 
recurrent  laryngeal  nerve;  S.T.,  superior  thyroid  artery  and  vein;   Tr.,  trachea. 


360  NECK  AND  TONGUE. 

ruptures  (cj'stic  goitre)   during  this  step  the  wall  of  the  cyst  should 
be  peeled  out. 

The  cavity  is  packed,  temporarily,  with  strip  gauze  to  check  the 
hemorrhage.  The  packing  is  allowed  to  remain  for  a  few  minutes 
and  then  removed.  If  the  hemorrhage  has  ceased  a  ping  of  strip 
gauze  is  introduced  into  the  cavity  and  the  incision  in  the  capsule 
sutured  except  its  lower  part  where  the  gauze  drain  emerges.  If  the 
temporary  tamponade  fails  to  control  the  hemorrhage  then  the  in- 
cision in  the  capsule  must  be  held  wide  open  with  retractors  and  in- 
dividual bleeding  points  sought  for  and  ligated.  If  the  hemorrhage 
is  a  profuse  general  oozing  the  packing  may  be  replaced  and  firm 
pressure  apjolied  with  a  snug  bandage.  Caution  must  be  exercised 
that  the  pressure  of  the  bandage  is  not  sufficient  to  comj^ress  the 
trachea  to  such  a  degree  as  to  interfere  seriously  with  respiration. 
In  order  finally  to  control  the  bleeding  it  may  be  necessary  to  ligate 
the  main  arterial  branches  that  suj)ply  the  gland  or  else  to  extirpate 
the  half  of  the  gland  that  has  been  incised. 

The  incision  in  the  skin  is  closed  by  suture  except  the  part  below 
where  the  drainage  strips  emerge. 

LiGATioisr  OP  Thyroid  Arteeies. — This  plan  of  treatment  has 
been  employed  in  the  hope  of  bringing  about  a  permanent  shrinkage 
of  the  goitre,  but  it  has  failed  to  yield  satisfactory  results. 

Ligation  of  the  superior  thyroid  arteries  and  veins  of  one  or  of 
both  sides,  or  of  the  superior  thyroid  artery  and  vein  and  the  inferior 
thyroid  artery  of  the  same  side,  is  frequently  practiced  in  cases  of 
exophthalmic  goitre  where  the  symptoms  of  thyroidism  are  very  ex- 
aggerated. By  this  plan  the  supply  of  blood  to  the  gland  is  reduced 
and  the  urgent  S3Tnptoms  ameliorated  to  such  a  degree  that  the  ex- 
tirpation of  the  gland  may  be  undertaken  with  more  prospect  of  sue-' 
cess  at  a  subsequent  date. 

For  the  method  of  exposing  the  superior  and  inferior  thyroid 
arteries,  etc.,  see  page  234. 

External  CEsophagotomy. — This  operation  is  usually  done  for  the 
removal  of  a  foreign  body  impacted  in  the  oesophagus.  The  patient, 
lies  upon  the  back,  with  the  shoulders  raised  and  the  head  thrown 
back  and  over  toward  the  right  side. 

A  soft-rubber  tube,  or,  better,  a  steel  sound,  is  introduced  into 
the  oesophagus  as  far  as  it  will  go  to  serve  as  a  guide.  The  oesophagTis 
is  approached  through  an  incision  in  the  left  side  of  the  neck  be- 
cause it  is  more  accessible  upon  this  side  than  u^Don  the  right. 


OPERATIONS  UPON  THE  OESOPHAGUS.  261 

The  incision  is  made  about  three  incites  hjiig,  corresponding  to 
the  anterior  border  of  the  left  stemo-mastoid  muscle,  the  midpoint  of 
the  incision  being  upon  a  level  with  the  cricoid  cartilage.  The 
incision  is  carried  through  the  skin  and  fat,  including  the  platysma, 
and  exposes  the  anterior  edge  of  the  sterno-mastoid  muscle. 
The  sterno-mastoid  is  drawn  aside  and  the  underlying  layer  of 
deep  cervical  fascia  is  incised,  when  the  internal  jugular  vein  and 
the  common  carotid  artery,  lying  in  their  connective-tissue  sheath 
and  crossed  by  the  anterior  belly  of  the  omo-hyoid  muscle,  are  ex- 
posed. These  vessels  are  drawn  outward  with  a  blunt  retractor. 
The  lateral  lobe  of  the  thyroid  gland,  partly  covered  by  the  sterno- 
hyoid and  sterno-thyroid  muscles,  is  then  recognized.  These  struc- 
tures are  drawn  toward  the  middle  line  with  a  blunt  retractor.  The 
trachea,  which  may  now  be  readily  felt  with  the  fingers,  is  a  guide 
to  the  oesophagus,  the  oesophagus  being  located  posterior  to  the  trachea 
and  protruding  well  beyond  its  left  border.  The  tube  in  the  oesoph- 
agus assists  in  locating  it,  and  the  foreign  body,  if  present,  may 
also  be  felt.  The  middle  thyroid  vein,  as  it  passes  outward  from 
the  thyroid  gland  to  enter  the  internal  jugular,  may  be  met  with,  and, 
if  it  is  in  the  way,  may  be  cut  and  tied.  The  inferior  thyroid  vein 
may  also  be  seen. 

The  oesophagus  is  entered  in  the  inferior  carotid  triangle, — i.e., 
below  the  omo-hyoid, — and,  if  necessary,  this  muscle  may  be  drawn 
'to  one  side  or  divided.  The  recurrent  laryngeal  nen-e,  as  it  ascends 
to  enter  the  larynx,  lies  in  front  of  the  oesophagus,  in  the  space  be- 
tween the  trachea  in  front  and  the  oesophagus  behind,  and  should 
be  avoided  in  incising  the  oesophagus.  The  nerve,  during  the  course 
of  the  operation,  is  usually  not  encountered,  and  may  be  avoided  by 
making  the  opening  in  the  oespohagus  well  upon  the  side  and  thus 
keeping  away  from  the  front  of  the  tube. 

The  wall  of  the  oesophagus  is  picked  up  with  two  mouse-toothed 
forceps,  and  an  incision  made  corresponding  to  its  long  axis  and  of 
sufficient  length  to  permit  the  extraction  of  the  foreign  body  or  any 
other  necessary  manipulation. 

In  incising  the  oesophagus  one  should  make  a  c^ean  cut  in  order 
to  avoid  getting  between  the  layers  of  the  wall  of  the  tube,  which 
may  readily  happen  owing  to  the  looseness  of  the  tissue  between 
its  muscular  and  mucous  coats.  Some  oesophageal  branches  of  the 
inferior  thyroid  may  be  divided  in  making  the  opening  in  the  wall 
of  the  oesophagus  and  these  must  be  clamped  and  ligated. 


262  NECK  AND  TOXGUE. 

The  wound  in  the  wall  of  the  oesophagiis  may  be  closed  with 
several  interrupted  sutures  of  silk  or  chromicized  catgut,  but  the 
external  wound  in  the  neck,  leading  down  to  the  incision  in  the  oesoph- 
agus, should  be  packed  and  left  unsutured. 

If  the  object  of  the  operation  is  to  establish  a  permanent  fistula 
(oesophagostomy),  the  edges  of  the  incision  in  the  oesophagus,  includ- 
ing its  mucous  and  muscular  coats,  may  be  fixed  to  the  edges  of  the 
skin  incision  with  several  interrupted  silk  stitches. 

OPERATIONS  UPON  THE  TONGUE. 

Amputation  of  the  Tongue  (Koclier),  with  Preliminary  Ligation 
of  the  Lingual  Artery. — 'Amputation  of  the  tongue  according  to  the 
method  of  Kocher  has  many  advantages.  The  hemorrhage  is  easily 
controlled,  diseased  glands  are  readily  removed,  and  the  incision  is 
well  placed  for  drainage. 

The  first  step  of  the  operation  consists  in  ligating  the  lingual 
artery  npon  the  side  corresponding  to  the  diseased  half  of  the  tongue. 

The  lingual  artery  is  a  vessel  of  considerable  size,  that  of  each 
side  supplying  the  corresponding  half  of  the  tongue.  It  is  sought 
for  and  tied  in  the  lingual  triangle. 

The  patient  lies  upon  the  back  with  the  shoulders  raised  upon 
a  sand-bag,  and  the  head  thrown  back  and  turned  a  little  toward  the 
other  side. 

Ether  is  probably  the  best  anassthetic.  administered  either  l)y 
the  drop  method  or  with  the  Grwathmey  vapor  apparatus  and  Lum- 
bard's  nasal  tubes.  It  is  of  advantage  to  give  the  patient,  one-half 
hour  before  the  operation,  one-quarter  grain  of  morphin  and  one- 
one  hundred  and  fiftieth  of  atropin  by  hypodermic. 

An  incision  is  made  which  corresponds  to  the  boundaries  of  the 
submaxillary  triangle.  It  commences  in  front  at  the  s}Tnphysis  mentis 
and  is  carried  down  to  the  hyoid  bone,  thence  backward  above  and 
parallel  with  the  greater  horn  of  the  hyoid  bone  and  then  in  a 
direction  upward  and  backward  toward  the  mastoid  process  as  far 
as  the  angle  of  the  lower  jaw  (see  Fig.  138).  The  incision  penetrate'^ 
through  the  skin,  fat,  and  platysma,  down  to  the  deep  fascia.  The 
apex  of  the  flap,  which  is  thus  marked  out,  is  seized  with  the  fingers 
and  reflected  upward  upon. the  side  of  the  face  as  far  as  the  lower 
border  of  the  jaw-bone.  In  reflecting  this  flap  we  msij,  toward  the 
back,  cut  the  external  jugular  vein,  and  this  should  be  clamped  and 
tied.     The  deep  fascia  is  incised  and  the  contents  of  the  triangle  ex- 


OPERATIONS  UPON  THE  TONGUE.  263 

posed.  These  consist  of  the  siibiiuixillary  salivary  gland  and  a  num- 
ber of  lymph-nodes.  The  lymph-nodes  will  be  found  diseased  and 
matted  together,  and  adherent  to  the  submaxillary  salivary  gland 
so  that  these  structures  will  usually  be  removed  in  one  mass.  The 
mass  is  seized  with  volsella  forceps  and  enucleated  by  cutting  with 
the  knife  close  to  the  surface  of  the  mass,  or  by  blunt  dissection 
Avith  the  handle  of  the  knife  or  with  the  fingers.  The  mass  is  finally 
cut  away  by  dividing  the  duct  of  the  submaxillary  gland,  which  is 
(Seen  to  disappear  anteriorly  beneath  the  posterior  border  of  the  mylo- 
hyoid muscle  on  its  way  to  open  into  the  anterior  part  of  the  floor 
of  the  mouth.  The  facial  artery,  if  not  previously  cut,  is  usually  di- 
vided in  enucleating  the  gland  mass  from  the  triangle  and  should  be 
tied  when  cut,  or,  still  better,  it  may  be  secured  and  tied  before  it 
is  cut,  close  to  its  origin  and  before  it  reaches  the  submaxillary  gland. 
The  facial  vein  is  also  usually  divided  during  this  part  of  the  opera- 
tion; this  vessel  bleeds  freely,  but  may  be  clamped  and.  ligated. 

The  boundaries  of  the  submaxillary  triangle  are  readily  recog- 
nized after  its  contents  have  been  dissected  out.  Above  the  lower 
l)order  oi  the  jaAv  and,  below,  in  front  and  behind  the  anterior  and 
posterior  bellies  of  the  digastric  muscle.  The  floor  of  the  submaxil- 
lary triangle  is  formed  in  front  by  the  oblique  fibers  of  the  mylo- 
hyoid and  behind  by  the  perpendicular  fibers  of  the  hyo-glossus,  which 
muscle  lies  on  a  deeper  plane  than  the  mylo-hyoid,  being  partly 
overlapped  by  the  posterior  margin  of  the  latter.  Passing  from  be- 
hind, horizontally  forward,  above  and  parallel  Avith  the  liA'oid  bone 
and  lying  directly  upon  the  hyo-glossus  muscle  is  the  hypo-glossal 
nerve;  this  nerve  disappears  anteriorly  beneath  the  posterior  edge 
of  the  mylo-hyoid  muscle.  This  nerve  marks  the  upper  boundary 
of  the  lingual  triangle,  which  is  really  the  apex  of  the  submaxillary 
triangle.  The  base  of  the  lingual  triangle  is  formed  by  the  hypo- 
glossal nerve,  and  its  lower  borders,  in  front  and  behind,  by  the  an- 
terior and  posterior  bellies  of  the  digastric.  The  floor  of  the  lingual 
triangle  is  formed  by  the  hyo-glossus,  and  beneath  this  muscle  the 
lingual  artery,  accompanied  by  a  vein,  is  located;  so  that,  if  this 
muscle  is  picked  up  Avith  tooth  forceps  and  snipped  through  with  the 
knife  or  scissors,  the  lingual  artery  is  readily  found  and  may  be 
hooked  up  with  an  aneurism  needle  and  tied.  Locating  and  tying 
the  lingual  artery  in  this  triangle  is  not  difficult. 

After  the  diseased  submaxillary  lymph-nodes  and  the  submaxil- 
lary salivary  gland  have  been  dissected  out  and  the  lingual  artery 


264  NECK  AND  TONGUE. 

ligated  and  all  bleeding  points  clamped  and  tied,  we  are  ready  to 
proceed  with  the  next  step  of  the  operation — ^the  actual  excision  of 
the  tongue.  Before  beginning  this  step  of  the  operation,  however, 
measures  must  be  taken  to  prevent  the  entrance  of  blood-  into  the 
larynx.  The  patient  may  be  placed  with  the  head  hanging  low  in 
the  Eose  position;  or  a  preliminary  tracheotomy  may  be  done  and  a 
Trendelenburg  tampon  cannula  introduced,  or  an  ordinary  trache- 
otomy tube  may  be  used  and  the  pharynx  tamponed  with  gauze. 

An  incision  is  made  with  the  knife  through  the  floor  of  the 
submaxillary  triangle,- — i.e.,  through  the  mylo-hyoid  muscle  and  the 
mucous  membrane  of  the  mouth, — close  to  the  inner  surface  of  the 
body  of  the  lower  jaw.  This  opening  may  be  farther  enlarged  with 
the  scissors  or  fingers.  The  tip  of  the  tongue  is  then  seized  with  a 
forceps  and  drawn  out  into  the  wound  in  the  neck,  through  the 
opening  in  the  floor  of  the  mouth,  and  making  considerable  traction, 
first  to  one  side  and  then  to  the  other,  the  tongue  is  cut  away  from 
its  attachment  to  the  floor  of  the  mouth,  as  far  back  toward  the  base 
as  possible.  This  is  done  with  the  blunt-pointed  curved  scissors, 
snipping  through  the  septum  of  the  tongue  and  working  close  to  its 
under  surface.  During  this  step  of  the  operation,  and  while  traction 
is  being  made  upon  the  tongue,  one  should  examine  occasionally  with 
the  finger  for  bands,  etc.,  which  tend  to  bind  the  tongue  within  the 
mouth.  The  anterior  pillars  of  the  fauces,  which  are  attached  to  the 
sides  of  the  tongue,  near  its  base,  should  be  cut  close  to  the  surface 
of  the  tongue,  and  then  it  will  be  observed  that  the  organ  can  be 
drawn  out  of  the  mouth  for  a  considerable  distance,  when  it  may  be 
amputated  quite  close  to  its  root.     This  is  done  with  the  scissors. 

The  half  of  the  tongue,  corresponding  to  the  side  upon  which 
the  lingual  has  been  tied,  may  be  cut  through  without  occasioning 
any  bleeding;  but,  if  the  lingual  artery  of  the  other  side  has  not 
been  previously  tied,  the  hemorrhage,  when  this  second  half  of  the 
tongue  is  cut  through,  may  be  embarrassing,  as  there  may  be  some 
difficulty  in  catching  the  cut  end  of  the  artery.  This,  however,  may 
be  provided  against  by  seizing  the  base  of  the  tongue  with  a  toothed 
clamp  behind  the  point  where  it  is  intended  to  amputate  it  before 
cutting  through;  so  that,  when  we  divide  this  half  of  the  tongue, 
we  may  pull  the  stump  forward,  and  seize  the  divided  vessel,  when 
it  spurts,  with  an  artery  clamp. 

The  wound  in  the  side  of  the  neck  is  closed  with  interrupted 
silla\^orm-gut  sutures,  except  its  posterior  part,  which  is  left  open 


OPERATIONS  UrON  THE  TONGUE.  265 

and  packed  to  carry  off  the  secretions,  etc.,  from  the  mouth.     The 
packing  should  be  introduced  well  into  the  cavity  of  the  mouth. 

The  patient  is  given  fluids — ^saline  solution — freely  by  rectum  for 
the  first  twenty-four  or  forty-eight  hours.  Later  the  patient  may  be 
fed  through  a  stomach  tube  which  is  passed  through  the  nose.  The 
patient  lies  with  the  head  low  and  turned  upon  the  side  to  facilitate 
drainage. 

Extirpation  of  the  Tongue  through  the  Mouth  with  Preliminary 
Ligation  of  the  Lingual  Artery  on  Both  Sides. — This  plan  is  applica- 
ble to  all  those  cases  of  cancer  of  the  tongi;e  where  the  floor  of  the 
mouth  is  not  yet  involved — where  the  tongue  is  not  fixed — and  it 
would  seem  that  these  are  really  the  only  cases  that  offer  a  favorable 
prospect  of  cure  through  operation. 

The  lingual  artery  corresponding  to  the  side  of  the  tongue  which 
is  diseased  is  exposed  by  an  incision  similar  to  that  already  described 
on  page  262,  which  opens  up  the  submaxillary  triangle.  The  contents 
of  the  triangle  are  dissected  out  and  the  lingual  artery  tied.  The 
lingual  artery  of  the  other  side  is  exposed  by  making  an  incision 
reaching  from  the  middle  line  backward,  above  and  parallel  with 
the  hyoid  bone,  and  curving  upward,  posteriorly,  toward  the  mastoid 
process.  The  incision  on  this  side  of  the  neck  does  not  need  to  be 
as  extensive  as  upon  the  other  side  unless  the  lymph-nodes,  etc.,  upon 
this  side  are  also  diseased  and  require  to  be  extirpated.  The  lingual 
artery  upon  this  side  is  secured  and  ligated.  The  incisions  on  both 
sides  of  the  neck  are  closed  with  a  sufficient  number  of  interrupted 
sutures,  without  drainage. 

The  anaesthetic  is  now  withdrawn  and  the  patient  permitted  to 
come  partly  out  so  that  he  can  keep  his  larynx  clear  of  blood.  The 
shoulders  are  raised  high  upon  a  sandbag — Eose  position — and  the 
mouth  held  wide  open  with  a  gag.  The  tong-ue  is  seized  at  the 
tip  and  drawn  forcibly  forward  out  of  the  mouth,  and  cut  away 
from  its  attachment  to  the  floor  with  blunt-pointed  scissors  and 
amputated  far  back  with  the  scissors.  This  part  of  the  operation  can  be 
done  very  quickly;  there  is  little  or  no  hemorrhage,  and  the  patient 
will  have  recovered  sufficiently  from  the  influence  of  the  angesthetic  to 
keep  the  larynx  clear  of  blood  by  coughing  and  expectorating.  It  is  ne- 
cessary to  precede  the  operation  by  administering  a  liberal  dose  of 
morphin  and  atropin  hypodermically.  The  edges  of  the  stump  of  the 
tongue  can  be  brought  together  with  one  or  two  sutures  of  heavy  silk. 
These  sutures  are  introduced  with  a  small,  stout,  full-curved  needle. 


266  NECK  AND  TONGUE. 

Within  a  short  time  the  patient  can  swallow  fluids  without  much 
gagging  and  may  sit  up  and  get  out  of  bed  in  a  few  days. 

Extirpation  of  a  Portion  of  the  Tong^ue. — The  patient  may  be 
placed  in  a  half-sitting  posture.  Anassthesia  is  not  complete. 
A  liberal  dose  of  morphin  may  be  administered  hypodermically  shortly 
before  the  operation,  and  only  sufficient  ether  or  chloroform  used  to 
keep  the  patient  fairly  quiet.  In  this  way  sufficient  reflex  is  retained 
to  enable  the  patient  to  keep  the  larynx  clear  of  b^ood  by  coughing 
and  expectorating. 

This  operation  may  be  advisable  in  early  suspicious  cases  where 
the  disease  is  strictly  limited  and  for  purpose  of  obtaining  a  specimen 
for  microscopic  examination  before  resorting  to  amputation  of  the 
entire  tongue. 

The  jaws  are  separated  with  a  gag  and  the  mouth  held  wide 
open  with  flat,  angular  retractors  placed  in  either  corner.  A  strong 
silk  suture  is  passed  through  the  tip  of  the  tongue  and  with  this 
as  a  tractor  the  tongue  is  drawn  well  forward  and  the  diseased  por- 
tion resected  with  the  scissors.  It  may  be  desired  to  resect  the  en- 
tire half  of  the  tongue  which  is  diseased.  If  so,  the  tongue  is  split 
down  the  middle  with  the  scissors,  and  the  diseased  half  separated 
from  the  floor  of  the  mouth  and  amputated  as  far  back  toward  the 
root  of  the  organ  as  desired.  If  the  lingual  artery  has  not  been  tied 
as  a  preliminary  step  to  the  operation,  the  bleeding  vessel  must  be 
seized  with  the  artery  forceps  in  the  stump  of  the  tongue  and  ligated. 
In  excising  a  portion  of  the  tongue  one  should  cut  wide  of  the  apparent 
diseased  area.  The  edges  of  the  raw  surface  are  brought  together  with 
interrupted  sutures  of  rather  heavy  silk.  This  operation  will  prob- 
ably suffice  for  very  early  cases  where  the  disease  is  distinctly  local 
and  the  lymphatics  are  not  yet  involved. 

Amputation,  of  the  Tongue  (Regnoli-Billroth). — This  method  is 
applicable  to  those  cases  where  the  floor  of  the  mouth  is  considerably 
involved  in  the  disease. 

The  patient  is  placed  in  the  Eose  position,  or  if  a  preliminary 
tracheotomy  has  been  done  and  a  Trendelenburg  tampon  cannula 
introduced  into  the  trachea,  or  if  an  ordinary  tracheotomy  tube  has 
been  introduced  and  the  pharynx  has  been  tamponed,  the  patient 
may  lie  in  the  usual  position  with  the  shoulders  raised  and  the  head 
thrown  back. 

An  incision  is  made  along  the  lower  border  of  the  body  of  the 
jaw  about  6  cm.  long,  the  midpoint  of  the  incision  corresponding 


OPERATIONS  UPOX  THE  TONGUE.  267 

to  the  symphysis  mentis.  Tliis  incision  penetrates  through  all  the 
soft  parts  down  to  the  bone  and  extends  backward,  upon  either  side, 
nearly  as  far  as  the  anterior  edge  of  the  masseter  muscle.  In  making 
this  incision,  the  facial  artery,  as  it  turns  up  over  the  lower  border 
of  the  jaw-bone,  just  in.  front  of  the  masseter,  may  be  avoided. 

From  either  end  of  this  incision  additional  ones  are  made  which 
reach  straight  downward  as  far  as  the  hyoid  bone,  passing  through 
tlie  integument  and  the  platysma.  Through  the  lateral  incisions,  on 
either  side,  the  lingual  artery  may  be  sought  and  tied,  at  the  same 
time  extirpating  any  diseased  glands,  etc. 

The  cavity  of  the  mouth  is  now  entered  by  severing  the  muscles 
attached  to  the  inner  surface  of  the  body  of  the  lowej  jaw  with  a 
knife.  They  should  be  cut  fairly  close  to  the  bone,  and  the  point 
of  the  knife  may  be  guided  with  the  finger  in  the  mouth.  Those 
muscles  that  are  attached  to  the  inner  aspect  of  the  symphysis  in 
the  middle  line  are  divided  first.  A  suture  should  be  passed  through 
the  tip  of  the  tongue  or  it  may  be  seized  with  a  toothed  clamp  in  order 
to  exercise  traction  and  prevent  its  falling  back  into  the  pharynx  and 
obstructing  the  breathing  during  the  course  of  the   operation. 

After  a  sufficiently  large  opening  has  been  made  in  the  floor  of 
the  mouth,  the  tongue  is  drawn  through  the  wound,  under  the  jaw, 
and  may  then  be  removed  together  with  the  floor  of  the  mouth  as 
far  back  as  the  epiglottis. 

If  the  lingual  arteries  have  not  been  previously  ligated,  the  base 
of  the  tongue  should  be  seized  with  a  volsella  forceps  before  it  is 
amputated,  in  order  to  facilitate  the  clamping  of  these  vessels  in  the 
stump  of  the  tongue. 

The  flap  of  skin  and  soft  parts  is  replaced  and  the  wound  closed 
except  posteriorly,  on  one  or  both  sides,  where  the  incision  is  left 
open  and  packed  in  order  to  drain  the  cavity  of  the  mouth. 

Extirpation  of  the  Tongue  through  the  Floor  of  the  Mouth,  with 
Division  of  the  Lower  Jaw. — The  operation  is  preceded  by  a  trache- 
otomy and  the  introduction  of  a  Trendelenburg  tampon  cannula,  or 
an  ordinary  tracheotomy  tube  may  be  used  and  the  pharynx  tam- 
poned. After  the  operation  the  patient  is  fed  per  rectum  or  through 
a  rubber  tube  which  is  passed  through  the  nose  down"  into  the  stomach. 

Sedillot^s  Method,  with  Divisio^r  of  the  Louver  Jaw  in"  the 
]\IiDDLE  Line. — The  first  incisor  tooth  of  the  lower  jaw  is  extracted. 
An  incision  is  made,  as  in  the  Eegnoli-Billroth  operation,  along  the 
lower  border  of  the  jaw  and  reaching  as  far  as  the  masseter  on  either 


268  NECK  AND  TONGUE. 

side.  The  lower  lip  is  then  split  in  the  middle  line,  the  incision 
being  carried  down  to  the  bone  through  the  gum  and  periosteum.  The 
lower  jaw  is  then  sawn  through  with  a  Gigli  saw,  and  the  muscles 
and  the  mucous  membrane  composing  the  iloor  of  the  mouth  incised 
close  to  the  inner  surface  of  the  body  of  the  lower  jaw-bone. 

Each  half  of  the  jaw  is  now  drawn  well  outward,  awa)^  from 
the  middle  line,  thus  giAdng  very  free  access  to  the  tongue  and  to  the 
floor  of  the  mouth.  The  tongue  and  that  part  of  the  floor  of  the 
mouth  which  is  involved  in  the  disease  may  then  be  extirpated. 

If  the  Unguals  have  not  been  previously  tied,  they  may  be 
clamped  after  the  tongue  has  been  amputated,  drawing  the  stump 
of  the  tongTie  forward  with  a  volsella  in  order  to  facilitate  this. 

The  tonsils  and  the  pillars  of  the  fauces  may  also  be  reached 
in  this  operation,  and,  if  the  lower  jaw-bone  is  involved,  it  can  be 
resected  in  part.  Diseased  l5'mphatic  glands  in  the  neck  may  also 
be  excised  through  this  incision,  which  may  be  made  as  extensive 
as  necessary. 

One  should  attempt  to  bring  the  raw  surfaces  in  the  mouth 
together,  at  least  in  part,  with  interrupted  chromicized  catgut  or 
silk  sutures,  their  ends  being  left  long  to  facilitate  their  removal 
later. 

The  two  halves  of  the  jaw  are  brought  together  and  carefulh^ 
wired,  and  the  incision  closed  except  at  its  posterior  part  on  one  or 
both  sides,  where  it  is  left  open  for  packing  and  drainage. 

Langenibeck's  Method,  with  Divisioisr  of  the  Lower  Jaw 
ON"  One  Side. — ^Upon  the  side  corresjDonding  to  the  disease  an  in- 
cision is  carried  from  the  comer  of  the  mouth  through  the  lower 
lip  as  far  as  the  lower  border  of  the  jaw,  whence  it  is  continued 
downward  through  the  integument  of  the  neck  as  far  as  the  side  of 
the  hjoid  bone.  The  upper  part  of  this  incision  splits  the  lip  and 
gum,  passing  through  the  periosteum  down  to  the  bone;  the  lower 
part  of  the  incision  passes  through  the  skin,  fat,  and  platysma.  .  All 
bleeding  points  are  clamped. 

Through  the  lower  part  of  the  incision,  after  cutting  through  ■ 
the  deep   fascia,  the  submaxillary  gland  and  the  neighboring  dis- 
eased lymphatic  "nodes  of  this  side  may  be  removed,  and  the  lingual 
artery  tied  as  it  lies  in  the  lingual  triangle,  above  the  hyoid  bone 
and  beneath  the  hyo-glossus  muscle. 

The  canine  tooth  of  the  lower  jaw  is  extracted  and  an  opening 
made  in  the  floor  of  the  mouth  so  as  to  allow  the  passage  of  the 


OPERATIONS  UPOX  THE  TONGUE.  269 

wire  saw  with  which  the  Jaw-bone  is  divided.  The  section  tlirough 
the  jaw  should  be,  nut  straight  up  and  down,  but  obliquely  from 
above  downward  and  inward  toward  the  symphysis,  so  that  the  tend- 
ency to  dislocation  caused  by  the  pull  of  the  masseter  muscle  may 
thus  be  counteracted.  The  jaw-bone  may  be  divided  with  a  narrow, 
flat  saw  or  with  a  wire  saw. 

The  segments  of  the  divided  jaw-bone,  especially  the  shorter 
piece,  are  now  drawn  well  apart  with  sharp  retractors,  and  the  soft 
parts,  muscles  and  mucous  membrane,  which  form  the  floor  of  the 
mouth,  separated  from  their  attachment  to  the  inner  surface  of  the 
bone,  as  far  back,  if  need  be,  as  the  anterior  pillars  of  the  fauces. 
The  tongue  is  then  seized  with  the  toothed  forceps  and  drawn  well 
forward  and  over  toward  the  well  side  and  removed.  One  may  ex- 
cise the  floor  of  the  mouth,  the  pillars  of  the  fauces,  and  the  tonsils, 
if  they  are  diseased,  and  also  resect  a  part  of  the  jaw-bone  if  this 
is  involved. 

If  the  Unguals  have  not  been  previously  ligated,  we  may  clamp 
them  in  the  stump  after  the  tongue  has  been  amputated.  The  seg- 
ments of  the  jaw-bone  are  brought  into  apposition  and  wired,  and 
the  wound  in  the  soft  parts,  except  its  lower  part,  which  is  left  open 
and  packed  to  carry  off  the  secretions  from  the  mouth,  is  closed  with 
interrupted  silkworm-gut  sutures. 

One  should  try  to  diminish  the  raw  surface  left  in  the  Iniccal 
ca^aty  as  much  as  possible  by  drawing  the  parts  together  with  sepa- 
rate chromicized   catgut   sutures. 

Billroth's  Method,  with  Bilateeal  Division  of  the  Lower 
Jaw. — This  is  probably  not  so  satisfactory  as  the  preceding  opera- 
tions, owing  to  the  difficulty  of  getting  union  of  the  loose  segment 
of  the  jaw. 

The  canine  tooth  upon  either  side  of  the  lower  jaw  is  extracted, 
and  an  incision  made  from  each  corner  of  the  mouth,  through  the 
lower  lip,  gum,  and  periosteum,  down  to  the  bone,  and  continued 
downward,  in  the  neck,  through  the  skin,  fat,  and  platysma  as  far 
as  the  hyoid  bone. 

Corresponding  to  the  place  upon  either  side  where  the  canine 
tooth  has  been  extracted  the  lower  jaw  is  sawn  through,  from  its 
upper  border  do^^Tiward  to  its  lower  border;  this  may  be  done  with 
the  wire,  or  flat  saw. 

The  soft  parts,  which  correspond  to  the  floor  of  the  mouth  and 
which  are  attached  to  the  middle,  loose  segment  of  the  jaw-bone,  are 


270  XECK  AND  TONGUE. 

separated  iijoon  the  inner  aspect  of  the  bone,  and  the  flap  of  soft 
parts,  which  includes  the  free  middle  segment  of  the  bone,  is  re- 
flected downward. 

The  lingual  arteries  may  be  ligated  and  diseased  glands  re- 
moved through  the  incisions  in  the  neck  previous  to  amputating  the 
tongue,  or  the  arteries  may  be  clamped  and  ligated  in  the  stump 
after  the  tongue  has  been  cut  away.  We  gain  free  access  to  the  floor 
of  the  mouth,  tonsils,  etc.,  in  this  operation. 

The  segments  of  the  jaw  are  finally  wired  together  and  the  in- 
cisions closed  except  the  lower  part,  upon  one  or  both  sides,  which 
may  be  left  open  and  packed  for  drainage. 


PART  IV. 

THE  THORAX. 


THE  SURGICAL  ANATOMY  OF  THE  THORACIC  WALL. 

The  Skeleton  of  the  Thorax. — The  thorax  consists  of  a  conical 
cage  of  bone  and  cartilage.  Entering  into  its  construction  are  the 
dorsal  vertebrae,  ribs,  sternum,  and  interposed  costal  cartilages.  The 
spaces  between  the  ribs  and  costal  cartilages  are^  filled  in,  and  the 
walls  of  the  chest  thus  completed,  by  the  intercostal  muscles. 

The  thoracic  cavity  is  rather  cone-shaped,  with  its  base  below 
and  its  small  end  above,  and  is  somewhat  flattened  from  before  back- 
ward. 

The  upper  orifice  of  the  thorax  is  kidney-shaped,  narrow  from 
before  backward,  and  broader  from  side  to  side.  It  is  bounded  in 
front  by  the  upper  border  of  the  sternum,  behind  by  first  dorsal 
vertebra,  and  laterally,  on  each  side,  by  the  first  rib.  The  first  rib 
is  set  very  obliquely;  so  that  its  anterior  end  strikes  a  much  lower 
level  than  its  posterior  end.  The  upper  border  of  the  sternum  is 
opposite  the  intervertebral  cartilage  between  the  second  and  third 
dorsal  vertebrae. 

The  lower  opening  of  the  thorax  is  large.  It  is  bounded  by  the 
lower  border  and  tip  of  the  twelfth  rib,  the  tip  of  the  eleventh  and 
the  costal  cartilages  of  the  tenth,  ninth,  eighth,  and  seventh  ribs. 
Anteriorly,  in  the  middle  line,  is  the  ensiform  cartilage;  posteriorly 
is  the  body  of  the  last  dorsal  vertebra. 

A  transverse  section  through  the  middle  of  the  thoracic  cavity 
shows  it  to  be  rather  heart-shaped,  owing  to  the  projection  forward 
of  the  bodies  of  the  vertebra.  On  either  side  of  the  vertebral  col- 
umn there  is  a  longitudinal  recess,  which  serves  to  deepen  the  space 
for  the  accommodation  of  the  lungs;  this  is  called  the  fossa  pul- 
monis. The  cartilages  of  the  lower  ribs,  the  seventh  to  the  tenth, 
meet  at  the  lower  end  of  the  sternum  and  form  an  angle  the  apex 
of  which  corresponds  to  the  ensiform  cartilage.  This  is  known  as 
the  costal  angle. 

The  thoracic  cavity  is  closed  in,  below,  by  the  diaphragm,  which 
projects  upward,  dome-like,  into  the  cavity  of  the  chest,  forming  its 

(271) 


272  THORAX. 

floor  and  at  the  same  time  the  roof  of  the  abdominal  cavity.  By  the 
projection  of  the  diaphragm  upward  into  the  chest  the  capacity  of 
the  chest  cavity  is  diminished  and  that  of  the  abdomen  correspond- 
mglj  increased.  In  the  living  body  the  chest  appears  to  be  broader 
above,  at  the  shoulders,  than  below  at  the  waist;  this  appearance  is 
due  to  the  broad  shoulder  girdle,  which  partially  encircles  the  chest 
above  and  which  is  made  up  of  the  clavicle  and  the  scapula  of  either 
side. 

The  space  within  the  chest  consists  of  an  air-tight  compartment 
on  either  side,  each  containing  one  of  the  lungs,  and  a  middle  space 
called  the  mediastinum,  in  which  are  lodged  the  heart  and  the  great 
vessels  at  its  base,  the  trachea,  oesophagus,  thoracic  duct,  and  the 
thymus  gland  or  its  remains. 

The  Doksal  Veetebe^.  —  These  are  twelve  in  number  and 
form  the  back  part  of  the  skeleton  of  the  chest.  They  give  stability 
to  the  thorax  and  at  the  same  time,  on  account  of  the  presence  of 
the  elastic  intervertebral  pads,  free  motion  is  allowed  in  all  direc- 
tions. 

This  part  of  the  vertebral  column  shows  a  sagittal  curve  with 
its  concavity  forward  and  a  slight  lateral  curve  with  its  concavity 
toward  the  left  (aorta). 

The  Eibs  are  twelve  in  number  (may  be  eleven  or  thirteen)  on 
each  side.  They  are  flat  bones  articulated  behind  to  the  vertebrae 
and  directed  obliquely  downward  and  forward.  They  form  the  bony 
frame-work  of  the  back,  sides,  and  part  of  the  front  of  the  chest. 

The  lower  the  rib  is  situated,  the  greater  is  its  inclination  down- 
ward.   They  increase  in  length  from  the  flrst  to  the  eighth. 

The  first  to  the  seventh  are  true  ribs:  i.e.,  they  are  each  con- 
nected individually,  through  their  cartilages,  with  the  sternum. 

The  eighth  to  the  twelfth  are  false  ribs:  their  cartilages  do  not 
articulate  with  the  sternum.  The  eighth,  ninth,  and  tenth  ribs  are 
indirectly  connected  with  the  sternum  through  the  junction  of  their 
respective  costal  cartilages  with  those  of  the  ribs  which  immediately 
adjoin  them  above. 

The  eleventh  and  twelfth  are  floating  ribs;  they  are  short  and 
their  cartilages  are  free. 

The  lower  border  of  each  rib,  upon  its  inner  aspect,  is  grooved 
for  the  lodgment  of  the  corresponding  intercostal  vein,  artery,  and 
nerve,  that  being  their  order  from  above  downward. 

The  first  rib  is  important  surgically.    It  is  very  short,  and  its 


SURGICAL  AXATOMV  OF  THE  THORACIC  WALL.  273 

surfaces  look  almost  directly  upward  and  downward.  It  is  set  so 
obliquely  that  its  posterior  end,  head,  articulates  with  the  upper 
part  of  the  body  of  the  first  dorsal  vertebra,  whereas  its  anterior 
end,  at  its  attachment  to  the  sternum,  is  upon  a  level  with  the  inter- 
vertebral pad  between  the  second  and  third  dorsal  vertebras.  The 
inner  border  of  this  rib  presents  a  tubercle  for  the  attachment  of 
the  scalenus  anticus  muscle;  external  to  this  tubercle,  upon  the 
upper  surface  of  the  rib,  there  is  a  groove  for  the  subclavian  artery. 
The  subclavian  vein  also  passes  across  the  upper  surface  of  the  first 
rib,  but  internally  to  the  artery,  the  tendon  of  the  scalenus  anticus 
being  interposed  between  the  two  vessels. 

The  inner  border  of  the  first  rib  is  in  direct  relation  with  the 
dome  of  the  pleura  and  the  apex  of  the  lung. 

The  Costal  Cartilages. — These  are  the  elastic  bands  which 
join  the  ribs  to  the  sternum  (except  the  eleventh  and  twelfth).  The 
cartilage  of  the  first  rib  is  very  short.  The  first  and  second  costal 
cartilages,  as  they  pass  to  the  sternum,  are  directed  somewhat  down- 
ward like  their  ribs.  The  cartilage  of  the  second  rib  articulates 
with  the  sternum  at  the  junction  of  the  manubrium  with  the  glad- 
iolus. The  cartilage  of  the  third  rib  is  directed  horizontally;  the 
cartilages  of  the  fourth,  fifth,  sixth,  and  seventh  ribs  are  directed 
upward  with  increasing  obliquity  as  they  pass  to  the  sternum.  The 
cartilages  of  the  eighth,  ninth,  and  tenth  make  quite  a  sharp  turn 
upward  toward  the  sternum  at  the  angle  of  junction  with  their  ribs, 
and  do  not  reach  the  sternum  directly,  but  are  fixed  each  to  the 
cartilage  immediately  above,  and  finally,  through  the  junction  of  the 
cartilage  of  the  eighth  rib  with  that  of  the  seventh,  to  the  sternum. 
The  cartilages  of  the  eleventh  and  twelfth  ribs  are  short  and  free. 

The  Sternum. — This  bone  is  rarely  fractured,  owing  to  the 
elasticity  of  the  parts  with  which  it  articulates.  It  consists  of  a 
manubrium,  or  handle;  a  gladiolus,  or  body;  and  a  cartilaginous  tip, 
the  ensiform  or  xiphoid  cartilage.  The  junction  between  the  manu- 
brium and  the  body  is  marked  by  a  prominent  transverse  line,  and 
presents  an  angle  directed  forward:  angulus  Ludovici.  This  trans- 
verse ridge,  which  is  readily  felt  under  the  skin,  is  an  important 
landmark  in  counting  the  ribs:  it  corresponds  to  the  articulation  of 
the  costal  cartilage  of  the  second  rib  with  the  sternum. 

The  ensiform  cartilage  varies  in  length  and  shape;  its  lower 
extremity  is  usually  on  a  level  with  the  tenth  dorsal  vertebra;  it 
may  be  bifurcated  or  deflected  to  one  side.     The  junction  of  the 


274  THORAX. 

ensiform  cartilage  with  the  body  of  the  sternum  corresponds  with 
the  line  that  marks  the  lower  border  of  the  heart  as  it  lies  within 
the  chest  behind  the  sternum. 

The  Muscles  of  the  Chest  Wall.  The  Intercostal  Muscles 
are  placed  between  the  ribs  and  costal  cartilages,  and  consist  of  two 
sets :  external  and  internal. 

The  External  Intercostals. — ^The  fibers  of  the  external  inter- 
costals  have  a  direction  similar  to  those  of  the  external  oblique  muscle 
of  the  abdomen :  that  is  from  above  downward  and  forward.  In  front, 
between  the  costal  cartilages,  the  muscular  fibers  are  absent,  their 
place  being  taken  by  aponeurotic  bands,  the  ligamenta  intercostalia 
anterior,  which  represent  the  muscles. 

The  Internal  Intercostals. — The  direction  of  the  fibers  of  the 
internal  intercostal  muscles  is  the  reverse  of  those  of  the  external. 
They  correspond  to  the  internal  oblique  muscles  of  the  abdomen, 
and  their  fibers  have  a  similar  direction:  upward  and  forward.  Be- 
hind, the  internal  intercostals  are  deficient,  their  place  being  occu- 
pied by  aponeurotic  sheaths :  the  ligamenta  intercostalia  posterior. 

The  Triangularis  Sterni  is  situated  anteriorly  within  the  chest. 
It  is  a  thin  sheet  of  muscle  which  is  attached  along  the  lateral  border 
of  the  posterior  aspect  of  the  sternum.  It  spreads  upward  and  out- 
ward in  four  or  five  processes,  which  are  attached  separately  to  the 
inner  surfaces  of  the  cartilages  of  the  second  to  the  sixth  ribs.  The 
internal  mammary  artery  is  located  between  this  muscle  and  the  costal 
cartilages.  The  costal  layer  of  the  pleura  is  applied  directly  against 
the  posterior  surface  of  the  triangularis  sterni.  The  triangularis 
sterni  is  the  transversus  thoracis  anterior  of  Henle. 

The  Musculi  Subcostales  are  a  few  sets  of  muscular  fibers  that 
are  found  upon  the  internal  surfaces  of  the  posterior  ends  of  the  ribs 
near  the  vertebral  column ;  the  direction  of  the  fibers  of  these  muscles 
is  similar  to  that  of  the  internal  intercostals:  they  reach  from  the 
inner  surface  of  one  rib  to  the  first  or  second  rib  above.  These  mus- 
cles correspond  to  the  musculus  transversus  thoracis  posterior  of  Henle, 
and  together  with  the  triangularis  sterni  are  the  analogues  of  the  trans- 
versus  abdominis,  the   deepest  of  the  flat  muscles  of  the  abdomen. 

The  Fasciae  of  the  Chest. — A  thin  fascia  covers  the  outer  surface 
of  the  ribs  and  the  external  intercostals.  A  similar  fascia  is  spread 
over  the  inner  surface  of  the  ribs  and  the  internal  intercostals,  tri- 
angularis sterni,  and  subcostales.  This  fascia  corresponds  to  the  fascia 
transversalis    of    the    abdomen,    and    is    known    as    the    fascia    endo- 


SURGICAL  ANATOIMY  OF  THE  THORACIC  WALL.  275 

thoracica.  The  fascia  endothoracica  is  also  spread  over  the  thoracic 
surface  of  the  diaphragm.  It  lines  the  whole  inner  surface  of  the 
thoracic  cavity,  and  is  everywhere  interposed  between  the  parietal 
layer  of  the  pleura  and  the  inner  surface  of  the  chest,  serving  thus 
to  bind  the  pleura  to  the  chest  wall  and  at  the  same  time  to 
strengthen  it.  Upon  the  posterior  surface  of  the  sternum  this  fascia 
forms  a  strong  fibrous  layer.  Above  it  projects  into  the  root  of 
the  neck  together  with  the  dome  of  the  pleura,  which  it  strengthens 
and  fixes  to  the  vertebras  and  to  the  deep  surface  of  scaleni  muscles, 
etc. 

The  Internal  Mammary  Artery  supplies  the  front  part  of  the 
intercostal  spaces  and  the  diaphragm  and  gives  perforating  branches 
to  the  muscles  of  the  chest  and  to  the  mammary  gland.  At  its  origin 
from  the  first  part  of  the  subclavian  artery  it  lies  behind  the  sub- 
clavian vein,  resting  upon  the  pleura,  and  is  crossed  by  the  phrenic 
nerve.  It  passes  down  into  the  thoracic  cavity  and  descends  along- 
side of  the  sternum,  a  distance  of  from  5  to  10  mm.  intervening 
between  it  and  the  lateral  border  of  this  bone.  Behind  the  seventh 
costal  cartilage  the  internal  mammary  artery  divides  into  the 
musculo-phrenic  and  the  superior  epigastric.  The  musculo-phrenic 
continues  downward  parallel  with  the  free  border  of  the  ribs,  sup- 
plying branches  to  the  intercostal  spaces.  The  superior  epigastric 
enters  the  posterior  sheath  of  the  rectus,  anastomosing  with  the  deep 
epigastric,  which  is  derived  from  the  external  iliac,  and  in  this  way 
forms  an  important  communication  between  this  trunk  and  the  sub- 
clavian. The  internal  mammary  artery  is  accompanied  by  two  veins, 
one  upon  either  side,  but  above  these  two  unite  to  form  a  single 
vein,  which  lies  to  the  inner  side  of  the  artery.  The  artery  is  also 
accompanied  by  a  chain  of  lymphatic  glands. 

Within  the  chest  the  artery  rests  upon  the  costal  cartilages  and 
the  internal  intercostal  muscles,  alongside  the  sternum,  and  is  sepa- 
rated from  the  parietal  pleura  by  the  fascia  endothoracica  and  the  tri- 
angularis sterni  muscle.  Opposite  each  intercostal  space  the  internal 
mammary  gives  off  an  intercostal  branch,  which,  passing  outward, 
divides  into  two,  and  these,  anastomosing  with  the  intercostal 
branches  from  the  aorta,  serve  to  establish  a  communication  between 
the  subclavian  and  the  aorta.  These  intercostal  branches  are  located 
between  the  internal  and  the  external  intercostal  muscles  close  to 
the  upper  and  lower  borders  of  the  contiguous  ribs.  The  internal 
mammary  gives  oE  perforating  branches,  which  pass  forward  through 


276  THORAX. 

the  intercostal  spaces  to  supply  the  muscles  of  the  breast  and  the 
mammary  glands.  Those  which  pass  through  the  second,  third,  and 
fourth  intercostal  spaces  are  large,  and  are  distributed  to  the  mam- 
mary gland. 

The  Diaphragm. — The  lower  orifice  of  the  thorax  is  closed  in 
by  the  diaphragm.  This  is  a  musculo-tendinous  partition  which 
separates  the  thoras  from  the  abdominal  cavity.  It  forms  the  floor 
of  the  thoracic  cavity  and  the  roof  of  the  abdomen.  The  thoracic 
surface  of  the  diaphragm  is  covered  by  the  fascia  endothoracica  and 
the  diaphragmatic  portion  of  the  parietal  pleura.  Its  middle  part 
from  before  backward  forms  the  floor  of  the  mediastinum,  and  upon, 
either  side  of  this  it  forms  the  bottom  of  each  iDleural  cavity. 

The  position  of  the  diaphragm,  immediately  after  death,  corre- 
sponds with  that  found  at  the  end  of  quiet  expiration  during  life, 
but  after  a  short  time,  owing  to  the  further  collapse  of  the  lungs, 
it  reaches  to  a  still  higher  level. 

Luschka  places  the  highest  point  reached  by  the  diaphragm 
at  the  end  of  forced  expiration  upon  the  right  side  at  the  level  of 
the  fourth  rib.  Most  authors  say  that  this  is  too  high  and  give,  in- 
stead, the  fourth  intercostal  space.  Upon  the  left  side  the  dia- 
phragm does  not  reach  as  high  as  upon  the  right  by  the  breadth  of 
one  rib. 

The  upper  orifice  of  the  thoracic  cavity  is  shut  in  on  either  side 
by  the  arcliing  subclavian  artery,  scalenus  anticus  and  medius  mus- 
cles, and  the  fascia  endothoracica.  This  fascia  is  intimately  blended 
with  the  dome  of  the  pleura,  and  attaches  the  same  to  the  adjacent 
fixed  points. 

THE  REGIONS  OF  THE  THORAX. 

The  following  imaginary  lines  serve  to  facilitate  the  location  of 
points  upon  the  thorax : — 

1.  The  midsternal,  which  passes  through  the  middle  of  the 
sternum. 

2.  The  lateral  sternal,  which  corresponds  to  the  lateral  border 
of  the  sternum. 

3.  The  mammary,  which  is  drawn  through  the  nipple. 

4.  The  parasternal,  which  is  drawn  midway  between  the  lateral 
border  of  the  sternum  and  the  mammary  line. 

5.  The  axillary,  which  is  located  midway  between  the  anterior 
and  the  posterior  borders  of  the  axilla. 


REGIOXS  OF  THE  THORAX.  277 

6.   The  scapular  passes  through  the  lower  angle  of  the  scapula. 
The  chest  is  divided  into  a  number  of  regions  as  follows: — 

1.  The  sternal. 

2.  The  upper  anterior  pectoral,  which  is  subdivided  into  a 
clavicular,  an  infraclavicular,  and  a  maiumary. 

3.  The  lower  anterior  pectoral. 

4.  The  lateral  pectoral. 

The  Sternal  Region. — This  region  corresponds  to  the  sternum. 
It  is  depressed  below  the  level  of  the  rest  of  the  chest,  especially 
in  muscular  subjects  and  in  females. 

The  skin  of  this  region,  in  the  male,  is  usually  covered  with  hair 
and  is  rich  in  sweat-glands.  The  subcutaneous  tissue  is  poor  in  fat 
and  allows  ready  palpation  of  the  sternum  beneath.  The  skin  and 
periosteum  covering  the  sternum  are  so  intimately  blended  with  each 
other  that  separation  betAveen  these  two  layers  is  somewhat  difficult, 
and,  therefore,  collections  of  blood  or  i}us  beneath  the  skin  in  this 
region  remain  circumscribed,  as  is  the  case  in  the  subcutaneous  tissue 
of  the  scalp.  Above,  we  observe  the  upper  notched  border  of  the 
sternum  with  the  sterno-clavicular  articulation  upon  either  side  and 
the  attachment  of  the  tendon  of  the  sterno-mastoid.  Below  is  the 
ensiform  cartilage,  to  which  is  attached  the  linea  alba.  The  junction 
of  the  manubrium  with  the  body  of  the  sternum  is  marked  by  a 
prominent  transverse  ridge  and  presents  an  angle  directed  forward: 
the  angle  of  Ludoviei.  The  sternum  forms  the  anterior  wall  of  the 
mediastinal  space,  and  its  posterior  surface  is  in  close  relation  with 
the  pleura  and  the  edges  of  the  lungs.  Below,  the  heart,  inclosed 
in  the  pericardial  sac,  lies  close  behind  the  sternum. 

The  Upper  Anterior  Pectoral  Region. — This  area  corresponds  to 
the  region  of  the  pectoralis  major  muscle,  and  shows  the  prominence 
of  the  breast  surmounted  by  the  nipple  and  the  areola.  The  skin  is 
soft,  especially  in  women,  and  during  lactation  is  marked  by  blue 
lines,  which  correspond  to  large  superficial  veins.  The  skin  is  freely 
movable,  owing  to  the  looseness  of  the  subcutaneous  tissue,  which 
is  rich  in  fat  and  within  which  the  mammary  gland  is  contained. 
The  mammary  gland  is  freely  movable  upon  the  underlying  pec- 
toralis major  muscle.  The  anterior  surface  of  the  pectoralis  major 
is  covered  by  a  thin,  cellular  fascia,  which  also  lines  the  posterior 
aspect  of  this  muscle.  Beneath  the  pectoralis  major  are  the  pec- 
toralis minor  and  the  subclavius  muscle.  The  pectoralis  major  and 
minor  form  the  front  wall  of  the  axilla. 


278  THORAX. 

The  Pectoealis  Major  is  a  broad,  flat  muscle  which  occupies 
all  of  this  region.  It  takes  its  origin  from  the  cartilages  of  the  six 
or  seven  upper  ribs  and  from  the  edge  of  the  sternum:  the  sternal 
portion  of  the  muscle.  It  also  arises  from  the  inner  half  of  the 
anterior  surface  of  the  clavicle:  the  clavicular  portion  of  the  mus- 
cle. From  these  points  of  origin  the  fibers  converge  to  form  a  flat 
tendon,  about  two  inches  broad,  which  is  attached  to  the  outer  edge 
or  lip  of  the  bicipital  groove:  a  depression  which  marks  the  upper 
part  of  the  front  of  the  humerus.  The  pectoralis  major  muscle  is 
covered  by  a  thin  fascia,  which  dips  down  between  its  fasciculi  and 
from  which  the  overlying  fat  and  mammary  gland  are  readily  sepa- 
rated. This  fascia  is  rich  in  lymphatics,  which  may  become  involved 
in  disease  of  the  mammary  gland.  Below,  this  fascia  is  continuous 
with  the  superficial  fascia  which  covers  the  abdominal  muscles  and 
laterally  with  that  which  covers  the  serratus  magnus.  It  dips  down 
into  the  space  between  the  deltoid  and  the  pectoralis  major,  and  is 
there  continuous  with  the  loose  fascia  that  invests  the  pectoralis 
minor  and  the  posterior  surface  of  the  pectoralis  major. 

The  Pectoralis  Minor. — This  muscle  is  exposed  by  dividing 
the  tendon  of  the  pectoralis  major  close  to  its  insertion  and  reflect- 
ing the  muscle  downward.  The  pectoralis  minor  arises  from  the  tip 
of  the  coracoid  process;  passing  downward  and  inward  and  becoming 
broader,  it  is  attached  to  the  third,  fourth,  and  fifth  ribs.  The 
pectoralis  minor  is  invested  by  a  fascia  which  is  continued  upward 
and  inward  beyond  the  upper  border  of  the  muscle,  covering  in  the 
first  part  of  the  axillary  artery  and  adjoining  structures  and  the  sub- 
clavius  muscle.  This  layer  of  fascia  is  called  the  costo-coracoid 
membrane  and  is  attached  to  the  under  surface  of  the  clavicle  and 
to  the  first  rib.  It  is  somewhat  thickened,  and  perforated  by  various 
vascular  and  nervous  branches,  which  pass  to  and  from  the  axillary 
vessels  and  adjacent  nerves. 

The  Subclavius  Muscle. — This  muscle  is  exposed  after  the 
costo-coracoid  membrane  has  been  removed.  It  arises  from  the 
under  surface  of  the  clavicle  and  passing  downward  and  inward  is 
attached  to  the  cartilage  of  the  first  rib. 

This  upper  anterior  pectoral  region  may  be  considered  as  the 
clavicular,  the  infraclavicular,  and  the  mammary  regions. 

The  Clavicular  Eegion".  —  The  clavicle  can  be  readily  pal- 
pated beneath  the  freely  movable  integument  which  covers  it  from 
its  inner  end,  where  it  articulates  with  the  sternum,  to  its  outer  end, 


REGIONS  OF  THE  THORAX.  379 

where  it  articulates  with  the  acromion  process  of  the  scapula.  The 
acromion  process  of  the  scapula  forms  the  most  external  and  promi- 
nent point  of  the  shoulder. 

Beneath  the  skin  in  the  clavicular  region  are  found  the  platysma 
and  the  deep  fascia. 

To  the  upper  surface  and  posterior  border  of  the  clavicle  are 
attached,  internally,  the  sterno-mastoid  muscle,  and  externally  the 
trapezius.  To  the  inner  half  of  the  front  surface  of  the  clavicle  is 
attached  the  pectoralis  major  muscle  (clavicular  portion),  and,  to 
its  outer  half,  the  deltoid  muscle. 

The  under  surface  of  the  clavicle  shows,  at  its  inner  end,  the 
attachment  of  the  rhomboid  ligament.  This  ligament  extends  be- 
tween the  under  surface  of  the  clavicle  and  the  cartilage  of  the  first 
rib.  External  to  this  the  subclavius  muscle  arises  from  the  under 
surface  of  the  clavicle. 

The  inferior  surface  of  the  outer  end  of  the  clavicle  is  con- 
nected with  the  coracoid  process  of  the  scapula  by  strong  ligamentous 
bands. 

Beneath  the  clavicle,  between  it  and  the  first  rib,  the  blood- 
vessels and  nerves  pass  from  the  root  of  the  neck  into  the  axilla. 

The  Ixfeaclaviculae  Eegion. — This  is  the  region  below  the 
clavicle.  Between  the  pectoralis  major  and  the  deltoid  muscle,  close 
to  the  clavicle,  there  is  a  triangular  depression,  the  fossa  of  Mohren- 
heim:   the  infraclavicular  fossa. 

In  the  space,  or  groove,  between  the  pectoralis  major  and  the 
deltoid  are  lodged  the  cephalic  vein  and  the  descending  branch  of 
the  acromio-thoracic  artery,  which  is  given  off  from  the  axillary. 
If  the  two  muscles  are  widely  separated,  we  expose  the  upper  part 
of  the  pectoralis  minor,  covered  by  its  fascia,  some  loose  connective 
tissue  and  fat,  and  the  coracoid  process.  This  process  is  readily  felt 
underneath  the  skin,  and  in  thin  persons  can  be  seen. 

If  the  pectoralis  major  is  cut  away  from  its  attachment  to  the 
clavicle  and  from  the  upper  part  of  the  sternum  and  reflected  down- 
ward, the  infraclavicular  region  proper  is  uncovered.  The  pectoralis 
minor  muscle  is  now  more  freely  exposed.  The  cephalic  vein  may 
be  seen  passing  from  without  inward  across  the  pectoralis  minor 
into  a  mass  of  fat  and  connective  tissue  on  the  inner  side  of  the 
muscle,  where  it  disappears  through  an  opening  in  the  costo-coracoid 
membrane  to  reach  the  first  part  of  the  axillary  vein,  which  lie3 
underneath  this  membrane. 


280  THORAX. 

The  acromio-thoracic  and  branches  of  the  superior  thoracic 
which  are  derived  from  the  axillary  artery  are  seen  to  emerge  through 
openings  in  the  costo-coracoid  membrane,  as  is  also  the  external 
anterior  thoracic  nerve,  which  supplies  the  pectoralis  major. 

The  costo-coracoid  membrane  is  a  sheet  of  fascia  which  is  con- 
tinued from  the  inner  or  upper  border  of  the  pectoralis  minor  mus- 
cle upward  and  inward,  and  is  attached  to  the  under  surface  of  the 
clavicle  and  to  the  first  rib;  it  covers  in  the  first  part  of  the  axillary 
aiteTj  and  the  structures  that  accompany  it  and  the  subclavius  mus- 
cle. When  the  costo-coracoid  membrane  is  removed,  we  expose  the 
first  part  of  the  axillary  artery  and  its  acromio-thoracic  and  superior 
thoracic  branches,  the  cords  of  the  brachial  plexus,  which  lie  above 
the  arter}^,  and  the  axillary  vein,  which  lies  below  and  internal  to  the 
artery.  The  cephalic  vein  may  be  seen  passing  across  the  axillary 
artery  to  enter  the  axillary  vein.  All  these  structures  are  gathered 
together  into  a  single  bundle,  and  are  accompanied  by  a  mass  of 
fat,  connective  tissue,  and  lymphatics  (see  Fig.  318). 

The  Mammaet  Region"  (Beeast).  —  The  mammary  gland  is 
rudimentary  in  the  male  and  naturally  well  developed  in  the  female. 
It  rests  upon  the  pectoralis  major  muscle  from  the  third  to  the  sixth 
rib.  In  unmarried  and  in  young  females  it  is  hemispheroidal,  firm, 
and  projects  forward;  but  after  child-bearing,  and  especially  in  some 
races  more  than  others,  it  is  pendulous,  and  hangs  down  over  the 
lower  part  of  the  thorax. 

The  skin  of  this  region  is  thin  and  fine  and  is  freely  movable 
upon  the  underlying  tissue.  The  superficial  veins  may  show  through 
the  skin  as  irregular  blue  streaks.  The  skin  of  the  nipple  is  espe- 
cially thin  and  pigmented,  and  may  be  fissured  and  split,  and  shows 
the  orifices  of  the  milk-ducts,  fifteen  to  twenty  in  number,  as  very 
fine,  needle-point  openings;  through  these  infection  may  reach  the 
mammary  gland  tissue  proper. 

In  the  unpregnant  the  nipple  is  depressed  and  pinkish,  but  is 
prominent  and  dark  colored  during  pregnancy.  The  nipple  is  sur- 
rounded by  a  pigmented  area,  areola,  which  is  fixed  to  the  under- 
lying tissue  and  marked  by  little  nodules  which  correspond  to  se- 
baceous and  sweat-glands. 

In  the  unmarried  the  mammary  gland  proper  is  small,  the  promi- 
nence of  the  breast  being  due  chiefly  to  the  abundance  of  the  fatty 
tissue  in  which  the  gland  is  imbedded.  It  does  not  reach  its  full 
development  until  after  pregnancy.     The  mammary  gland  is  a  tegu- 


REGIONS  OF  THE  THORAX.  281 

mentary  organ  inclosed  within  its  own  proper  fibrous  capsule  and 
lodged  in  the  subcutaneous  fat.  It  consists  of  a  number  of  lobules, 
which  are  separate  and  distinct  from  each  other;  so  that  the  secre- 
tion of  milk  and  nursing  may  be  continued  even  after  one  or  more 
lobules  have  become  the  seat  of  a  suppurative  process.  Between 
the  mammary  gland  and  the  anterior  surface  of  the  pectoralis  major 
muscle  there  is  a  layer  of  loose  fatty  tissue,  which  permits  the  gland 
to  be  freely  moved  about  upon  the  surface  of  the  muscle. 

Occasionally  a  process  of  gland  tissue  almost  entirely  discon- 
nected from  the  main  gland  may  be  found  lying  under  the  border 
of  the  pectoralis  major,  dipping  beneath  the  muscle  into  the  axilla. 
This  process  of  gland  tissue  is  often  difficult  to  recognize.  All  the 
ducts  of  the  gland  converge  from  the  periphery  toward  the  nipple; 
they  may  become  occluded  and  distended,  giving  rise  to  cystic  tumors 
whose  contents  consist  of  milk  or  of  a  buttery  material:   galactocele. 

The  arteries  of  the  breast  consist  of  perforating  branches  from 
the  internal  mammary,  especially  the  second  and  third  and  branches 
of  the  long  thoracic  from  the  axillary.  Of  the  veins,  the  superficial 
ramify  beneath  the  skin  and  the  deep  ones  accompany  the  arteries. 

The  lymphatics  are  important  and  of  these  there  are  two  sets: 
those  of  the  integument  and  those  which  drain  the  gland  proper. 
The  lymphatics  of  the  integument  are  very  superficial  and  numerous, 
especially  upon  the  nipple  and  in  the  areola;  corresponding  to  the 
region  of  the  areola,  they  form  a  fine  capillary  net-work  which 
spreads  outward  toward  the  periphery,  some  branches  dipping  in- 
ward to  enter  a  plexus  which  surrounds  the  milk-ducts  beneath  the 
skin  of  the  areolar  region.  The  lymphatics  from  the  gland  proper, 
from  the  acini  and  substance  of  the  gland,  are  abundant.  Accord- 
ing to  Sappay,  they  all  tend  toward  the  surface  and  end  as  good- 
sized  vessels  in  the  plexus  already  mentioned  which  surrounds  the 
milk-ducts  beneath  the  skin  of  the  areola.  The  lymph  from  this 
subareolar  plexus  is  collected  into  two  main  channels:  one  above 
and  one  below  the  nipple.  These  lymphatic  vessels  pass  outward 
toward  the  outer  border  of  the  gland,  and,  after  being  joined  by  one 
or  two  vessels  from  the  periphery  of  the  gland,  terminate  in  the 
nearest  lymphatic  nodes,  which  are  found  near  the  anterior  wall  of 
the  axilla  in  the  neighborhood  of  the  third  and  fourth  ribs,  being 
covered  usually  by  the  edge  of  the  pectoralis  major.  These  are,  as 
a  rule,  the  first  lymphatic  nodes  to  become  involved  in  disease  of 
the  mammary  gland.     The  lymphatic  nodes  in  the  root  of  the  neck 


282  THORAX. 

also  receive  tributaries  from  the  breast,  and  may  be  found  involved 
when  the  mammary  gland  is  diseased. 

The  Lower  Anterior  Pectoral  Ee^on. — This  is  the  area  which 
lies  between  the  lower  limits  of  the  pectoralis  major  muscle  and 
the  free  border  of  the  ribs.  This  region  is  important  surgically  only 
on  account  of  the  structures  which  lie  beneath  it,  within  the  chest 
and  abdomen. 

The  Lateral  Pectoral  Region. — This  space  is  included  between 
the  border  of  the  pectoralis  major  in  front  and  that  of  the  latissimns 
dorsi  behind.  It  presents  the  ribs  covered  by  serrations  of  the  ser- 
ratus  magnus  and  by  the  latissimus  dorsi  and  obliquus  abdominis 
externus. 

The  arteries  of  this  region  are  derived  from  the  axillary  (long 
thoracic)  and  intercostals.  The  posterior  thoracic  nerve  is  found  in 
this  region  descending  upon  the  serratus  magnus,  which  it  supplies. 

THE  MEDIASTINUM  AND  CONTENTS. 

The  mediastinum  is  a  space  within  the  chest,  between  the  two 
pleural  cavities,  which  is  occupied  by  the  heart  and  pericardium,  the 
thymus  or  its  remains,  the  trachea,  oesophagus,  aorta,  and  several 
nerves,  and  a  mass  of  loose  connective  tissue  and  lymphatics. 

Eather  more  of  the  space  lies  to  the  left  of  the  middle  line 
than  to  the  right.  It  is  limited  in  front  by  the  sternum,  behind  by 
the  vertebral  column,  and  its  floor  is  formed  by  the  diaphragm. 
Above,  the  loose  connective  tissue  of  this  space  is  continuous  into 
the  root  of  the  neck  with  that  which  surrounds  the  oesophagus  and 
trachea  and  the  great  vessels  in  the  neck.  Laterally  the  mediastinum 
is  walled  off  on  either  side  from  the  pleural  cavity  by  the  parietal 
pleura  (mediastinal  portion  of  the  parietal  pleura). 

The  mediastinum,  as  mentioned  above,  is  not  an  empty  space, 
but  is  fairly  closely  occupied  by  various  organs.  In  the  lower  part 
of  this  space,  in  front,  is  the  heart,  inclosed  within  its  pericardial 
sac;  behind  the  heart,  between  it  and  the  vertebral  column,  the 
space  is  not  large,  and  is  occupied  by  the  oesophagus,  thoracic  duct, 
thoracic  aorta,  vena  azygos,  vena  hemiazygos,  and  various  nerves. 
In  the  upper  part  of  the  mediastinum,  in  front,  is  the  thymus  or  its 
remains,  and  behind  this  the  trachea  and  oesophagus,  the  latter  lying 
just  in  front  of  the  vertebral  column.  Immediately  above  the  base 
of  the  heart  are  the  great  vessels  connected  with  the  heart — the  arch 


]\IEDIASTINUM  AND  CONTENTS. 


283 


of  the  aorta,  vena  cava  superior,  pulmonary  artery  and  its  branches 
— and  the  bifurcation  of  the  trachea.  A  number  of  lymphatic  glands 
which  communicate  with  the  lymphatics  of  the  neck  and  axilla  are 
packed  in  between  these  structures. 

The  Pericardium. — The  heart,  occupying  the  lower  anterior  part 
of  the  mediastinum,  lies  close  to  the  anterior  wall  of  the  chest 
(sternum)  inclosed  within  its  own  serous  sac,  the  pericardium.  The 
pericardium,  as  a  thin  serous  layer,  is  closely  applied  to  the  whole 
surface  of  the  heart  and  to  the  great  vessels  at  its  base  for  a  part  of 


Fig.  14-1. -Transverse  Section  through  Thorax  just  Above  the  Heart  and 
Root  of  the  Lungs.  A,  A,  aorta;  E8,  oesophagus;  LPA,  left  pulmonary  artery; 
MP,  mediastinal  pleura  passing  forward  to  the  posterior  aspect  of  the  root 
of  the  lung;  PA,  pulmonary  artery;  PE,  pericardium;  PN,  phrenic  nerve; 
PP,  parietal  layer  of  pleura;  PS,  space  between  parietal  and  visceral  layers 
of  the  pleura;  RB,  right  bronchus;  RPA,  right  pulmonary  artery;  S,  ster- 
num; VA,  vena  azygos;  VG,  vena  cava  superior;  TP,  visceral  layer  pleura. 


their  extent;  above,  after  inclosing  the  first  or  ascending  part  of  the 
arch  of  the  aorta,  it  is  reflected  as  a  thin,  loose,  membranous  sac, 
which  completely  envelops  the  heart  and  is  attached  below  by  its 
broad  base  to  the  dome  of  the  diaphragm.  The  highest  limit,  or  the 
apex,  of  the  pericardial  sac  is  that  portion  which  incloses  the  first  part 
of  the  arch  of  the  aorta.  Its  broad  base,  which  is  below,  corresponds 
to  its  attachment  to  the  diaphragm.    The  pulmonary  artery  is  also 


384  THORAX. 

included  within  the  pericardial  sac  as  far  as  its  bifurcation,  but  its 
two  divisions  are  not  included.  The  vena  cava  superior  is  also 
partially  invested. 

In  front,  the  pericardial  sac  is  in  relation  with  the  sternum 
and  the  costal  cartilages,  from  which  it  is  separated  by  the  inter- 
posed pleura  and  the  edges  of  the  lungs.  Behind  the  lower  part  of 
the  sternum  there  is  a  triangular  space — with  its  apex  above  upon  a 
level  with  the  fourth  costal  cartilage,  a  little  to  the  left  of  the 
middle  line,  and  its  basfe  below,  corresponding  to  the  junction  of  the 
body  of  the  sternum  with  the  ensiform  cartilage:  i.e.,  on  a  level 
with  the  articulation  of  the  sixth  costal  cartilage — where  the  peri- 
cardium lies  in  direct  relation  with  the  posterior  surface  of  the 
sternum.  Corresponding  to  this  area  the  pleura  and  the  edge  of  the 
lung  are  not  interposed  between  the  sternum  and  the  pericardial 
sac.  Occasionally,  according  to  some  descriptions,  the  edge  of  the 
left  pleura  fails  to  reach  the  left  border  of  the  sternum  behind  the 
fifth  costal  cartilage  and  fifth  intercostal  space,  and  under  these 
circumstances  one  could  puncture  through  the  fifth  space  close  to 
the  left  border  of  the  sternum  and  enter  the  pericardial  sac  without 
meeting  the  pleura.  In  all  cases  the  edge  of  the  left  lung  is  notched 
in  this  region,  incisura  cardiaca;  so  that,  although  one  'might  en- 
counter the  pleura  in  puncturing  in  this  situation,  he  would  not, 
in  any  case,  meet  the  lung.  Corresponding  to  the  incisura  cardiaca 
is  the  region  of, the  "cardiac  impulse,"  and  here  the  heart  is  most 
exposed.  Behind,  that  part  of  the  pericardial  sac  which  covers  the 
left  auricle  is  in  close  relation  with  the  oesophagus.  The  trachea 
bifurcates  just  above  and  close  to  that  part  of  the  pericardial  sac  that 
covers  the  left  auricle.  On  each  side  the  pericardium  is  firmly  ad- 
herent to  the  mediastinal  portion  of  the  parietal  pleura,  and  between 
the  apposed  layers  of  both  these  structures,  upon  either  side,  the 
phrenic  nerve  descends  in  its  course  to  reach  and  supply  the  dia- 
phragm. 

The  Heart. — The  heart,  inclosed  within  the  pericardial  sac,  is 
located  in  the  lower  anterior  part  of  the  mediastinum,  almost  com- 
pletely surrounded  by  the  lungs,  which  show  a  hollowed-out  cavity 
on  their  internal  surface  corresponding  to  the  size  and  shape  of 
the  heart.  The  impression  upon  the  left  lung  is  deeper  than  that 
upon  the  right. 

Behind  the  heart  is  the  vertebral  column,  and  in  the  space  be- 
tween the  heart  and  the  spinal  column,  in  the  lower  back  part  of 


mediaStinllm  and  contents.  285 

the  mediastinum,  are  the  oesophagus,  accompanied  by  the  pneumo- 
gastric  nerves;  the  thoracic  aorta  and  thoracic  duct;  the  vena 
azygos,  which  lies  to  the  right  of  the  vertebral  column;  and  the 
vena  hemiazygos,  which  lies  to  the  left  of  the  column. 

The  heart,  with  its  long  axis  directed  downward,  forward,  and 
to  the  left,  rests  with  its  posterior  surface,  which  is  composed  chiefly 
of  the  left  ventricle,  upon  the  central  tendon  of  the  diaphragm. 
Here  the  diaphragm  is  somewhat  flattened,  and  to  the  right  of  the 
middle  line  is  perforated  for  the  passage  of  the  vena  cava  inferior. 
This  vessel,  after  passing  through  the  diaphragm,  enters  almost  im- 
mediately the  lower  contiguous  part  of  the  right  auricle. 

The  anterior  surface  of  the  heart,  composed  mainly  of  the  right 
ventricle  and  auricle,  lies  close  to  the  posterior  surface  of  the  ster- 
num and  costal  cartilages,  from  which  it  is  separated,  for  the  most 
part,  by  the  pleura  and  the  lungs,  these  being  interposed  between 
the  heart  and  the  sternum  and  costal  cartilages. 

The  base  of  the  heart,  which  is  directed  upward  and  backward 
toward  the  spinal  column,  is  made  up  of  the  auricles;  the  right 
auricle  is  placed  anteriorly,  and  receives  above  the  vena  cava  supe- 
rior and  below  the  vena  cava  inferior;  the  left  auricle  forms  the 
posterior  part  of  the  base,  lying  close  to  the  oesophagus,  and  receives 
the  pulmonary  veins  from  either  lung. 

The  apex  of  the  heart,  the  lowest  part  of  the  left  ventricle,  is 
found  in  the  fifth  left  intercostal  space  midway  between  the.  para- 
sternal and  mammary  lines. 

Above  the  heart  are  the  arch  of  the  aorta,  with  the  superior 
vena  cava  placed  close  upon  the  right  side  of  its  first  or  ascending 
part,  the  pulmonary  artery  and  its  bifurcation,  the  bifurcation  of 
the  trachea,  and  a  mass  of  lymphatic  glands  and  fat. 

The  Outlines  of  the  Heart  upon  the  Chest  Wall. — The 
lower  border  of  the  heart  corresponds  to  the  line  of  junction  between 
the  body  of  the  sternum  and  its  ensiform  cartilage.  The  upper 
border  of  the  heart  corresponds  to  the  upper  border  of  the  third 
costal  cartilage.  To  the  right  of  the  sternum  lies  the  right  auricle, 
its  boundary  corresponding  to  a  curved  line  which  is  drawn  from  the 
articular  end  of  the  third  costal  cartilage  downward  and  through  the 
fifth  costal  cartilage  close  to  its  articulation  with  the  sternum.  The 
right  ventricle  reaches  over  for  a  considerable  distance  to  the  left 
of  the  sternum,  with  a  portion  of  the  left  ventricle  adjoining  and 
forming  the  left  border  of  the  heart.     The  apex,  the  extreme  end 


286 


THORAX. 


of  the  left  ventricle,  is  situated  in  the  fifth  intercostal  space  midway 
between  the  parasternal  and  the  mammary  lines. 

One-third  of  the  heart  lies  to  the  right  and  two-thirds  to  the 
left  of  the  middle  line. 

The  pulmonary  orifice,   valve,   corresponds   to   a  line  which  is 


Pig.  145. — Outline  of  Heart  and  Location  of  Valves.  A,  aortic  orifice,  left 
eemilunar  valve  (dotted  line) ;  P,  orifice  of  pulmonary  artery,  right  semi- 
lunar valve;  T.M.,  line  of  right  and  left  auriculo-ventricular  orifice.  Upper 
part  of  line  corresponds  to  left  auriculo-ventricular  orifice,  mitral  valve. 
Lower  part  of  line  corresponds  to  right  auriculo-ventricular  opening,  tri- 
cuspid valve.  Position  of  the  diaphragm  is  indicated  by  the  curved  line  that 
passes  below  the  inferior  border  of  the  heart. 

placed  upon  the  junction  of  the  third  costal  cartilage  with  the  left 
border  of  the  sternum,  half  of  the  line  upon  the  cartilage  and  half 
upon  the  sternum. 

The  aortic  orifice,  valve,  may  be  indicated  by  a  line  drawn  from 


MEDIASTINUM  AND  CONTENTS.  287 

the  junction  of  the  third  costal  cartilage  with  the  left  border  of  the 
sternum,  just  below  the  line  indicating  the  pulmonary  valve  and 
diverging  from  this,  as  far  as  the  middle  line,  to  a  level  with  the 
third  space. 

The  auriculo-ventricular  openings  are  represented  by  a  line  ex- 
tending from  the  lower  border  of  the  third  left  costal  cartilage,  one 
finger's  breadth  beyond  the  left  border  of  the  sternum,  downward 
and  toward  the  right,  across  the  body  of  the  sternum,  as  far  as  the 
junction  of  the  sixth  right  costal  cartilage  with  the  right  border  of 
the  sternum.  The  lower  part  of  this  line  represents  the  tricuspid 
(right  auriculo-ventricular)  orifice  and  the  upper  part  represents  the 
mitral  (left  auriculo-ventricular)  orifice. 

The  Thymus. — The  thymus  body  in  the  newborn  is  located  in 
the  upper  front  part  of  the  mediastinum  behind  the  sternum  and 
in  front  of  the  upper  part  of  the  pericardial  sac.  Its  upper  portion 
reaches  well  upward,  in  front  of  the  trachea,  into  the  root  of  the 
neck.  In  the  upper  part  of  the  mediastinal  space  the  thymus  lies 
directly  in  front  of  the  trachea,  the  left  innominate  vein,  which 
passes  from  left  to  right,  across  the  front  of  the  trachea,  being  in- 
terposed between  them.  In  the  root  of  the  neck  the  thymus  lies 
upon  the  front  of  the  trachea,  and  is  in  relation,  on  either  side,  with 
the  common  carotid  artery  and  the  internal  jugular  vein. 

The  lower  part  of  the  thymus  lies  behind  the  body  of  the  ster- 
num and  in  front  of  the  great  vessels  at  the  base  of  the  heart,  dip- 
ping down  between  the  pericardial  sac  and  the  edges  of  the  lungs 
and  pleura. 

The  thymus  increases  in  size  from  birth  until  the  second  year, 
and  then  remains  stationary  or  atrophies  slowly  until  puberty.  After 
puberty  it  atrophies  rapidly,  undergoing  fatty  changes. 

The  Arch  of  the  Aorta.  —  The  arch  of  the  aorta  is  well  sur- 
rounded by  the  lungs,  the  edges  of  which  nearly  meet  behind  the 
sternum. 

It  arises  from  the  left  ventricle,  and  at  its  origin  lies  behind 
the  root  of  the  pulmonary  artery.  It  first  passes  upward,  forward, 
and  toward  the  right  as  far  as  the  right  border  of  the  sternum;  it 
then  turns  backward  and  toward  the  left,  arching  over  the  left  bron- 
chus; and  near  the  upper  border  of  the  body  of  the  fourth  dorsal 
vertebra,  upon  its  left  side,  it  turns  downward  and  is  continued  as 
the  thoracic  aorta. 

The  arch,  as  it  passes  backward  and  to  the  left  over  the  left 


288  THORAX. 

bronchus,  reaches  its  highest  point,  which  is  upon  a  level  with  the 
upper  border  of  the  first  costal  cartilage. 

The  Ascexdixg  Paet  of  the  Aech. — Upon  the  right  side  and 
close  to  the  ascending  or  first  part  of  the  arch  lies  the  superior  vena 
cava,  which  enters  the  upper  part  of  the  right  auricle;  this  part  of 
the  arch  and  the  superior  vena  cava  are  situated  in  front  of  the  root 
of  the  right  limg.  The  vena  azygos,  passing  forward  from  the  right 
side  of  the  vertebral  column,  crosses  the  root  of  the  right  lung  and 
empties  into  the  vena  cava  superior  through  its  posterior  wall. 

The  Teaxsyeese  Paet  oe  the  Aech. — The  transverse  pa^t  of 
the  arch  passes  from  right  to  left  and  from  before  backward,  from 
the  right  border  of  the  sternum  to  the  left  side  of  the  body  of  the 
fourth  dorsal  vertebra,  arching  over  the  root  of  the  left  lung.  Its 
upper  border  is  upon  a  level  with  the  upper  border  of  the  first  costal 
cartilage.  From  the  upper  aspect  of  the  transverse  part  of  the  arch 
are  given  off  the  innominate  and  the  left  common  carotid  and  sub- 
clavian arteries. 

Below  the  transverse  part  of  the  arch  is  the  pulmonary  artery 
and  its  bifurcation,  the  branches  passing  transversely — one  to  the 
hilum  of  each  lung — and  lying  in  front  of  the  bronchi.  Behind  the 
transverse  part  of  the  arch,  in  the  back  part  of  the  mediastinum, 
the  trachea  and  the  oesophagus  are  located. 

In  front  of  the  transverse  part  of  the  arch  are  the  sternum, 
the  thymus  or  its  remains,  and  the  edges  of  the  pleura  and  the  edges 
of  the  Itmgs,  which  nearly  meet  directly  behind  the  sternum.  A 
little  above  and  in  front  of  the  transverse  part  of  the  arch,  passing 
from  left  to  right  across  the  middle  line,  is  the  left  innominate  vein. 
The  left  superior  intercostal  vein  passes  forward  from  the  third  left 
intercostal  space  near  the  spinal  column  and  enters  the  left  innomi- 
nate in  front  of  this  part  of  the  arch.  To  the  left  of  the  middle  line, 
the  left  pneumogastric  nerve  descends  in  front  of  and  close  to  the 
transverse  part  of  the  arch,  and  gives  off  its  recurrent  laryngeal 
branch,  which  curves  around  the  arch  and  ascends  into  the  neck. 
Also  descending  in  front  of  the  transverse  part  of  the  arch,  but 
nearer  the  middle  line  than  the  left  pneumogastric,  is  the  left 
phrenic  nerve. 

The  Pnenmogastric  Nerves. — These  pass  through  the  thoracic 
cavit}',  in  close  relation  with  the  cesophagus,  on  their  way  to  the 
stomach. 

The  right  pneumogastric,  at  the  root  of  the  neck,  lies  between 


MEDIASTIXU:\I  AXD  CONTEXTS.  389 

the  common  carotid  artery  and  the  internal  jugular  vein.  It  de- 
scends into  the  chest,  across  the  front  of  the  first  part  of  the  sub- 
clavian artery,  between  it  and  the  subclavian  vein.  Within  the  chest 
it  passes  obliquely  backward,  close  to  the  right  side  of  the  trachea 
and  across  the  posterior  aspect  of  the  root  of  the  right  lung,  where 
it  takes  part  in  the  formation  of  the  posterior  pulmonary  plexus. 
The  nerve  then  approaches  the  middle  line  and  descends  upon  the 
posterior  surface  of  the  oesophagus  and  through  the  oesophageal 
opening  in  the  diaphragm,  to  be  distributed  to  the  posterior  sur- 
face of  the  stomach. 

The  left  pneumogastric  dips  into  the  chest  between  the  left 
carotid  and  subclavian  arteries,  behind  the  left  innominate  vein,  and, 
descending  across  the  front  of  the  left  end  of  the  transverse  part 
of  the  arch  of  the  aorta,  is  continued  downward,  behind  the  root  of 
the  left  lung  and  thence  upon  the  front  surface  of  the  oesophagus 
and  through  the  diaphragm,  to  be  distributed  to  the  anterior  surface 
of  the  stomach. 

The  Ixferiok  Recurrent  Branches.  —  Upon  the  right  side 
the  inferior  recurrent  is  given  off  from  the  pneumogastric  as  it 
passes  across  the  front  of  the  first  part  of  the  subclavian  arte^}^ 
Curving  around  this  vessel,  it  ascends  in  the  neck,  in  the  recess  be- 
tween the  oesophagus  and  the  trachea,  to  enter  the  lower  part  of  the 
larynx. 

Upon  the  left  side  the  recurrent  is  given  off  as  the  pneumo- 
gastric passes  across  the  front  of  the  transverse  part  of  the  arch  of 
the  aorta.  It  winds  around  the  lower  border  of  this  part  of  the 
arch  and  ascends  in  the  neck,  having  a  similar  relation  to  the  oesoph- 
agus and  trachea  as  that  of  the  right  side. 

The  Phrenic  Nerves. — In  the  root  of  the  neck  the  phrenic  nerve 
of  either  side  may  be  seen  crossing  the  front  of  the  scalenus  anticus 
tendon  in  a  direction  from  above  downward  and  inward.  After  en- 
tering the  chest  they  pass  down  in  front  of  the  root  of  either  lung; 
the  left,  in  its  course,  passes  across  the  front  of  the  transverse  part 
of  the  arch  of  the  aorta  parallel  with  the  left  pneumogastric,  but 
more  internally,  nearer  the  middle  line;  the  right  passes  down  upon 
the  right  side  of  the  superior  vena  cava.  They  then  descend  between 
the  pericardium  and  the  mediastinal  portion  of  the  pleura  as  far  as 
the  diaphragm,  which  they  supply. 

The  Trachea. — This  is  an  elastic  membranous  tube  which  is  put 
upon  the  stretch  when  the  head  is  extended.     Set  into  its  wall  are 


290  THORAX. 

a  number  of  cartilaginous  plates,  each  forming  part  of  a  circle. 
These  cartilaginous  plates  are  absent  in  the  posterior  part  of  the 
trachea. 

The  trachea  is  the  continuation  of  the  larynx.  It  begins  in 
the  neck  below  the  cricoid  cartilage  at  the  sixth  cervical  vertebra, 
and  in  this  part  of  its  course  lies  quite  superficial.  As  it  passes 
downward  it  gets  to  lie  deeper,  farther  away  from  the  surface.  In 
the  chest,  opposite  the  fifth  dorsal  vertebra,  just  above  the  base  of 
the  heart,  the  trachea  divides  into  the  two  bronchi. 

In  front  of  the  trachea,  in  the  upper  part  of  the  mediastinum, 
are  the  sternum,  the  thymus  or  its  remains,  connective  tissue,  and 
fat.  It  is  crossed  from  left  to  right  and  obliquely  from  above  down- 
ward by  the  left  innominate  vein;  into  this  vein  in  front  of  the 
trachea,  one  on  each  side  of  the  middle  line,  empty  the  inferior  thy- 
roid veins.^  Occasionally  a  large  arterial  branch,  the  thyroidea  ima, 
arises  from  the  upper  aspect  of  the  transverse  part  of  the  arch  of 
the  aorta  and  ascends  upon  the  front  of  the  trachea.  Lower  down, 
the  trachea  is  crossed  by  the  transverse  part  of  the  arch  of  the  aorta 
and  the  vessels  arising  from  the  superior  aspect  of  this  vessel.  The 
innominate  and  left  carotid  arteries,  at  their  origin,  are  placed  in 
front  of  the  trachea.  The  right  pneumogastric,  in  the  upper  part 
of  the  chest,  lies  close  to  the  right  side  of  the  trach-ea.  The  oesoph- 
agus is  situated  behind  the  trachea.  It  is  intimately  related  to  the 
posterior,  non-cartilaginous  wall  of  the  trachea;  so  that  foreign 
bodies  lodged  in  the  cBSophagus  may,  by  pressure  upon  the  posterior 
wall  of  the  trachea,  seriously  narrow  its  lumen  and  produce  symp- 
toms of  strangulation.  In  the  immediate  neighborhood  of  the  bifur- 
ca.tion  of  the  trachea  are  twenty  to  thirty  lymphatic  nodes.    - 

The  CEsophagus.  —  The  oesophagus  is  the  continuation  of  the 
pharynx,  and  consists  of  a  thick  muscular  coat  with  a  mucous  mem- 
brane lining.  The  mucous  membrane  is  connected  with  the  mus- 
cular coat  by  a  very  loose  submucous  connective  tissue. 

When  collapsed,  the  oesophagus  appears  as  a  flat,  transverse 
band,  with  the  mucous  membrane  thrown  into  longitudinal  folds, 
and  upon  cross  section  it  shows  a  stellate  figure. 

The  oesophagus  commences  behind  the  cricoid  cartilage  on  a 
level  with  the  sixth  cervical  vertebra;  it  descends  through  the  neck 
and  thorax,  piercing  the  diaphragm  upon  a  level  with  the  tenth 


1  The  right  inferior  thyroid  often  empties  into  the  right  innominate. 


MEDIASTINUM  AND  CONTENTS.  291 

dorsal  vertebra,  and  terminates  at  the  cardiac  end  of  the  stomach 
upon  a  level  with  the  eleventh  dorsal  vertebra. 

In  the  neck  and  upper  part  of  the  thorax,  as  far  as  the  fourth 
dorsal  vertebra,  the  oesophagus  lies  close  to  the  front  of  the  vertebral 
column,  but  from  this  point  downward  it  gets  to  lie  farther  away, 
and  as  it  passes  through  the  diaphragm  it  is  located  quite  some  dis- 
tance in  front  of  and  to  the  left  of  the  tenth  dorsal  vertebra. 

The  oesophagus,  throughout  its  course,  is  surrounded  by  loose, 
cellular  tissue  by  which  it  is  connected  with  adjoining  structures. 
The  average  length  of  the  oesophagus  is  about  35  cm.,  and  the  dis- 
tance from  the  teeth  to  the  cardiac  orifice  of  the  stomach  is  about 
50  cm.  To  get  the  distance  from  the  mouth  to  the  cardiac  orifice 
of  the  stomach,  in  any  individual  case,  one  may  measure  from  the 
spinous  process  of  the  eleventh  dorsal  vertebra  to  that  of  the  ver- 
tebra prominens,  and  thence  across  the  shoulder  to  the  mouth. 

The  lumen  of  the  oesophagus  is  narrowest  at  its  commencement 
behind  the  cricoid  cartilage,  again  narrow  opposite  the  third  or 
fourth  dorsal  vertebra  and  again  as  it  passes  through  the  diaphragm. 
At  its  narrowest  part  the  caliber  of  the  oesophagus  has  a  diameter 
of  1-i  mm.,  but  it  is  capable  of  much  distension  beyond,  this. 

RELATION'S  OF  THE  CEsoPHAGUS.  Ill  the  NecJc  the  oesophagus  lies 
upon  the  front  of  the  spinal  column  and  immediately  behind  the 
trachea,  to  the  posterior  non-cartilaginous  wall  of  which  it  is  united 
by  loose  connective  tissue.  The  oesophagus,  situated  behind  the 
trachea,  protrudes  a  considerable  distance  beyond  the  left  border  of 
the  latter,  and  is  therefore  in  closer  relation  with  the  common 
carotid  artery,  internal  jugular  vein,  etc.,  upon  the  left  side  of  the 
neck  than  upon  the  right  side.  In  the  recess  between  the  trachea 
in  front  and  the  oesophagus  behind,  upon  either  side,  the  recurrent 
laryngeal  nerve  ascends  to  enter  the  lower  part  of  the  larynx.  Above, 
where  the  lateral  lobes  of  the  thyroid  gland  rest  upon  the  sides  of 
the  trachea,  they  reach  backward  so  as  to  get  into  close  proximity 
with  the  oesophagus. 

Within  the  Chest. — In  the  upper  part  of  the  chest  the  oesophagus 
is  still  situated  in  front  of  the  spinal  column  close  behind  the  trachea, 
protruding  somewhat  beyond  the  left  border  of  the  latter.  Opposite 
the  third  dorsal  vertebra  it  is  placed,  together  with  the  trachea,  be- 
hind the  transverse  part  of  the  arch  of  the  aorta.  Opposite  the 
fourth  dorsal  vertebra  the  descending  part  of  the  arch  of  the  aorta 
lies  to  the  left  side  of  the  oesophagus,  pushing  it  (the  oesophagus)  a 


292  THORAX. 

little  over  toward  the  right;  but  immediately  below  this  the  azygos 
vein,  appearing  upon  the  right  side  of  the  oesophagus,  forces  it  again 
to  the  left,  and  here  at  this  level  the  oesophagus  is  found  behind  the 
root  of  the  left  lung,  to  which  it  is  loosely  attached  by  connective 
tissue.  As  the  oesophagus  descends  it  remains  in  close  relation  with 
the  aorta,  which  vessel  gradually  passes  behind  it  in  order  to  reach 
the  middle  line  in  front  of  the  vertebral  column.  Opposite  the  eighth 
dorsal  vertebra  the  oesophagus  lies  in  front  of  the  aorta,  and  opposite 
the  tenth,  as  it  pierces  the  diaphragm  to  terminate  in  the  stomach, 
it  lies  in  front  and  to  the  left  of  the  aorta  and  spinal  column. 

In  the  space  behind  the  heart,  between  it  and  the  vertebral 
column,  in  the  lower  back  part  of  the  mediastinum,  the  oesophagus 
lies  in  close  proximity,  anteriorly,  with  the  left  auricle,  which  is 
enveloped  in  the  pericardial  sac.  In  this  space,  upon  the  right  side 
of  the  vertebral  column,  is  the  azygos  vein;  upon  the  left,  the 
hemiazygos;  and  in  front  of  the  vertebral  column,  the  thoracic  duct; 
the  aorta  is  situated  behind  the  oesophagus.  The  mediastinal  portion 
of  the  pleura,  as  it  passes  forward  to  the  root  of  the  lung,  is  reflected 
upon  either  side  of  the  oesophagus.  Descending  upon  the  anterior 
wall  of  the  oesophagus  is  the  left  pneumogastric,  and,  upon  its  poste- 
rior wall,  the  right  pneumogastric  nerve.  These  nerves  accompany 
the  oesophagus  through  the  oesophageal  opening  in  the  diaphragm 
and  are  distributed  to  the  stomach. 

The  Thoracic  Aorta. — This  is  the  continuation  of  the  arch.  It 
lies  at  first  upon  the  left  side  of  the  bodies  of  vertebrge,  but  as  it 
descends  it  approaches  the  middle  line,  and  finally,  as  it  passes  into 
the  abdomen  behind  the  diaphragm,  it  lies  in  front  of  the  body  of 
the  last  dorsal  vertebra.  Throughout  its  course  the  thoracic  aorta 
is  closely  related  to  the  oesophagus;  at  first  it  lies  to  the  left  side 
of  the  oesophagus,  but  as  it  descends  it  gets  behind  it,  between  it  and 
the  vertebral  column;  below,  the  oesophagus  is  placed  in  front  of 
and  to  the  left  of  the  aorta,  the  latter  (aorta)  as  it  passes  into  the 
abdomen  being  situated  upon  the  front  of  the  spinal  column.  The 
thoracic  aorta  gives  off  the  intercostal  branches:  one  for  each  inter- 
costal space  from  the  third  downward. 

The  Vena  Azygos. — This  vein  ascends  upon  the  right  side  of  the 
spinal  column;  it  is  made  up  of  branches  from  the  lumbar  region 
and  receives  the  intercostals  in  its  course.  About  the  level  of  the 
fourth  dorsal  vertebra  it  passes  forward  over  the  root  of  the  right 
lung,  and  enters  the  vena  cava  superior  through  its  posterior  wall. 


THE  PLEURA.  293 

Th'e  Vena  Hemiazygos. — The  origin  and  course  of  tliis  vessel  are 
analogous  to  those  of  the  azygos.  It  ascends  upon  the  left  side  of  the 
vertebral  column.  Opposite  the  eighth  dorsal  vertebra  the  vena 
hemiazygos  passes  across  the  front  of  the  spinal  column  behind  the 
aorta  and  thoracic  duct,  and  upon  the  right  side  of  the  verteljral  column 
joins  the  vena  azygos. 

The  Thoracic  Duct  passes  into  the  thorax  behind  the  diaphragm 
in  company  with  the  aorta,  between  this  vessel  and  the  front  of  the 
spinal  column.  As  it  ascends  through  the  thorax  it  lies  upon  the  bodies 
of  the  dorsal  vertebrae.  In  the  upper  part  of  the  chest  it  arches  forward 
and  outward  toward  the  left,  and  passes  over  the  first  part  of  the  sub- 
clavian artery,  to  enter  the  left  subclavian  vein  where  this  vessel  joins 
the  left  internal  jugular,  to  form  the  left  innominate,  just  to  the 
inner  side  of  the  tendon  of  the  scalenus  anticus. 

The  Innominate  Artery  has  a  calibre  corresponding  to  the  thick- 
ness of  the  little  finger.  It  springs  from  the  right  end  of  the  upper 
border  of  the  transverse  part  of  the  arch  of  the  aorta,  and  is  about 
5  cm.  long.  At  its  origin  it  lies  in  front  of  the  trachea ;  it  terminates 
by  dividing  into  the  subclavian  and  common  carotid  behind  the  right 
sterno-clavicular  joint. 

Situated  in  front  of  this  vessel  are  the  sternal  attachments  of  the 
sterno-hyoid  and  sterno-thyroid  muscles,  the  manubrium  of  the  ster- 
num, and  the  remains  of  the  thymus  gland.  The  left  innominate  vein 
passes  across  the  front  of  the  root  of  the  innominate  artery,  and  upon 
its  outer  (right)  side  joins  with  the  right  innominate  vein  to  form  the 
vena  cava  superior.  The  right  inferior  thyroid  vein,  as  it  descends 
from  the  lower  part  of  the  thyroid  gland  to  enter  the  right  innominate 
vein,  also  passes  across  the  front  of  the  innominate  artery.  To  the 
outer  side  of  the  innominate  artery  lie  the  right  pneumogastric  and 
the  right  phrenic  nerves  and  the  pleura  and  apex  of  the  right  lung. 
To  the  inner  side  of  the  innominate  is  the  left  common  carotid,  the  dis- 
tance between  the  two  vessels  varying. 

The  Left  Common  Carotid  and  Left  Subclavian  Arteries  arise  from 
the  upper  border  of  the  transverse  part  of  the  arch.  They  lie  deep 
within  the  chest,  and  are,  in  this  region,  not  subject  to  surgical 
interference. 

THE   PLEURA. 

The  pleura  of  each  side  is  a  completely  closed  fibro-serous  sac. 
It  lines  the  entire  inner  surface  of  the  cavity,  within  which  the  lung 


294  THORAX. 

is  contained,  and,  besides,  as  a  thin,  serous  layer,  invests  the  whole 
surface  of  the  lung. 

That  portion  of  the  pleura  which  is  applied  to  the  surface  of 
the  lung  is  called  the  visceral  layer,  and  that  which  lines  the  whole 
inner  surface  of  the  cavity  in  which  the  lung  is  contained  is  called 
the  parietal  layer.  That  part  of  the  parietal  pleura  which  lines  the 
inner  surface  of  the  wall  of  the  chest,  sternum,  costal  cartilage,  ribs, 
etc.,  is  spoken  of  as  the  pleura  stemo-costalis;  that  portion  which 
is  spread  out  upon  the  surface  of  the  diaphragm,  the  pleura  dia- 
phragmatica;  and  that  which  limits  the  mediastinum  on  each  side, 
passing  from  before  backward  like  a  partition  and  separating  the 
mediastinal  space  from  the  space  which  contains  the  lung,  is  called 
the  pleura  mediastinalis. 

The  parietal  layer,  after  lining  the  inner  surface  of  the  ribs, 
intercostal  muscles,  etc., — that  is,  the  whole  inner  aspect  of  the 
wall  of  the  thorax, — is  found,  behind,  upon  either  side  of  the  verte- 
bral column,  to  leave  the  posterior  wall  of  the  thorax  and  pass 
forward,  forming  the  posterior  part  of  the  mediastinal  pleura;  that 
of  the  left  side,  as  it  passes  forward,  covers  the  adjacent  wall  of 
the  aorta  and,  lower  down,  the  oesophagus;  that  of  the  right  side, 
as  it  passes  forward,  covers,  below,  the  side  of  the  vena  azygos  and, 
higher  up,  the  side  of  the  oesophagus.  Upon  reaching  the  posterior 
aspect  of  the  root  of  the  lung  the  pleura  is  reflected  on  to  the  sur- 
face of  the  lung  and  as  the  visceral  layer  completely  invests  it,  being 
also  continued  in  between  the  lobes  and  intimately  united  with  its 
surface;  after  thus  entirely  enveloping  the  lung  it  reaches  the  ante- 
rior aspect  of  the  root  of  the  lung,  whence  it  is  reflected  forward 
toward  the  sternum  as  the  anterior  portion  of  the  mediastinal  pleura; 
upon  reaching  the  posterior  surface  of  the  sternum  it  becomes  con- 
tinuous with  that  part  of  the  parietal  pleura  which  lines  the  inner 
surface  of  the  wall  of  the  chest:  the  pleura  sterno-costalis.  Above 
and  below  the  level  of  the  root  of  the  lung  the  mediastinal  pleura 
passes  all  the  way  as  an  uninterrupted  layer  from  behind  forward, 
from  either  side  of  the  spinal  column  to  the  posterior  surface  of  the 
sternum. 

Limits  of  the  Pleura  as  Indicated  by  Lines  upon  the  Chest  Wall. 
The  Anterioe  Edge  of  the  Pleura. — The  line  which  indicates 
the  anterior  edge  of  the  right  pleural  sac  commences,  above,  behind 
the  right  sterno-clavicular  articulation;  from  this  point  it  passes 
downward  and  inward  behind  the  sternum,  and  at  the  junction  of 


THE  PLEURA. 


295 


Fig.  146. — Outline  of  Pleura,  etc.  Front  view.  A,  apex  of  lung  and  dome 
of  pleura;  D,  line  of  diaphragm;  U,  outline  of  heart;  L,  solid  lines  show  the 
edges  of  the  lungs;  P,  dotted  lines  correspond  to  the  edges  of  the  pleura. 


296  THORAX. 

the  manubrmm  with  the  body  of  the  sternum  it  lies  close  to  the 
middle  line;  it  is  then  continued  downward  behind  the  middle  of 
the  body  of  the  sternum,  and  opposite  the  articulation  of  the  fourth 
costal  cartilage  it  curves  outward,  as  it  descends,  to  reach  a  point 
corresponding  to  the  lower  border  of  the  sternal  end  of  the  sixth 
costal  cartilage,  whence  it  may  be  traced  farther  downward  and 
backward  as  the  lower  edge  of  the  pleura. 

The  line  whkh  marks  the  anterior  edge  of  the  left  pleural  sac 
is  somewhat  different.  It  commences  above,  behind  the  left  sterno- 
clavicular articulation,  from  which  point  it  curves  downward  and 
inward  toward  the  middle  line  and  may  then  be  traced  downward 
behind  the  body  of  the  sternum  parallel  with  the  anterior  edge  of 
the  right  pleural  sac  to  a  point  upon  a  level  with  the  junction  of  the 
fourth  costal  cartilage  with  the  sternum;  here  it  curves  outward, 
but  more  obliquely  than  upon  the  right  side,  and  reaches  the  sternal 
end  of  the  sixth  costal  cartilage  at  its  upper  border,  whence  it  is  con- 
tinued obliquely  downward  and  backward  as  the  lower  edge  of  the 
pleura. 

According  to  Merkel,  the  anterior  edge  of  the  left  pleural  sac, 
upon  a  level  with  the  fourth  costal  cartilage,  passes  still  more 
obliquely  outward  than  has  been  described  above  so  as  to  strike  the 
sixth  costal  cartilage,  not  at  its  junction  with  the  sternum,  but  some 
little  distance  beyond  this  articulation,  thus  leaving  a  space  between 
the  anterior  edge  of  the  left  pleural  sac  and  the  left  border  of  the 
sternum,  corresponding  to  the  fifth  costal  cartilage,  fifth  intercostal 
space,  and  sixth  costal  cartilage,  which  is  not  covered  by  the  pleura. 
If  this  condition  were  present,  one  might  introduce  an  aspirating 
needle  into  the  pericardial  sac  through  the  fifth  intercostal  space, 
close  to  the  left  border  of  the  sternum,  without  encountering  the 
pleura. 

Without  doubt  the  anterior  edge  of  the  left  pleural  sac  is  sub- 
ject to  considerable  variation.  I  have  found  the  first  description  to 
hold  for  most  cases. 

The  Lower  Edge  of  the  Pleuea  corresponds  to  a  line  that 
commences,  in  front,  behind  the  junction  of  the  sixth  costal  carti- 
lage with  the  sternum;  it  passes  downward  and  backward,  crossing 
obliquely  the  cartilage  of  the  seventh  rib  in  the  parasternal  line  and 
passing  into  the  seventh  intercostal  space  in  the  mammary  line;  still 
continued  downward  and  backward  it  reaches  its  deepest  point,  cor- 
responding to  the  tenth  rib  or  tenth  intercostal  space,  a  little  behind 


THE  PLEURA. 


297 


298 


THORAX. 


the  axillary  line,  whence  it  may  be  traced  almost  horizontally  back- 
ward and  inward  to  the  articulation  of  the  twelfth  rib  with  the 
spinal  column.  Behind,  in  the  scapular  line,  the  lower  edge  of  the 
pleura  corresponds  to  the  tenth  intercostal  space. 

It  will  be  observed  that  the  lower  edge  of  the  pleura,  as  it  is 
reflected  from  the  inner  surface  of  the  chest  wall  over  on  to  the 
surface  of  the  diaphragm,  does  not  dip  down  into  the  bottom  of  the 
recess  between  the  costal  portion  of  the  diaphragm  and  the  ribs. 
This  space  varies  in  depth  at  different  parts.     Occasionally  the  lower 


Fig.  149.— Section  through  Seventh,  Eighth,  and  Ninth  Ribs  Anterior  to 
the  Axillary  Line.  D,  diaphragm;  EX,  external  intercostal  muscle;  IN,  in- 
ternal intercostal  muscle;  P,  pleura  covering  inner  aspect  of  the  chest  wall; 
PD,  pleura  that  covers  the  diaphragm;  PE,  peritoneum  that  is  reflected  upon 
the  under  surface  of  the  diaphragm;  VAN,  intercostal  vein,  artery,  and  nerve 
situated  under  lower  border  of  the  ribs;  7,  8,  9,  cut  surface  of  ribs;  *  repre- 
sents the  space  between  the  diaphragm  and  chest  wall  into  which  the  pleura 
does  not  descend,  as  it  is  reflected  from  the  chest  wall  on  to  the  upper  sur- 
face of  the  diaphragm. 

edge  of  the  pleura,  behind,  reaches  down  between  the  twelfth  rib  and 
the  diaphragm  as  far  as  the  lower  border  of  the  twelfth  rib,  or,  even 
beyond  this,  down  to  the  level  of  the  transverse  process  of  the  first 
lumbar  vertebra. 

The  Dome  of  the  pleura  is  that  part  of  the  pleural  sac  which 
projects  upward  into  the  root  of  the  neck  above  the  level  of  the  first 
rib ;  it  reaches  to  a  distance  of  5  cm.  above  the  level  of  the  anterior 
part  of  the  first  rib,  but  does  not  reach  above  the  level  of  the  back 
part  of  the  first  rib;  the  first  rib  is  set  very  obliquely,  its  anterior 
portion  being  upon  a  much  lower  level  than  its  posterior  part. 


LUNGS.  299 

The  dome  of  the  pleura  reaches  from  2  to  4  cm.  above  the  level 
of  the  clavicle;  so  that  a  knife  introduced  above  this  bone  and  passed 
directly  backward  would  pierce  both  the  pleura  and  the  lung.  In 
front  of  the  dome  is  the  first  rib  and  the  posterior  surface  of  the 
scalenus  anticus  muscle  and  the  clavicle.  Internal  to  the  dome  are 
the  trachea  and  the  oesophagus. 

The  subclavian  vessels  pass  forward  and  outward  across  the 
dome,  grooving  it  and  the  apex  of  the  lung,  which  lies  beneath.  Care 
is  necessary  in  ligating  the  subclavian  or  innominate  arteries  not  to 
wound  the  pleura. 

As  the  internal  mammary  artery  dips  down  into  the  chest  it  is 
crossed  by  the  phrenic  nerve  and  lies  in  close  relation  with  the  dome 
of  the  pleura. 

The  dome  of  the  pleura  is  re-enforced  by  the  fascia  endotho- 
racica,  and  connected  behind,  through  ligamentous  bands,  with  the 
first  rib  and  the  last  cervical  and  the  first  dorsal  vertebrae  and  in 
front  with  the  deep  surface  of  the  scaleni  muscles. 

The  mediastinal  portion  of  the  pleura  and  the  pericardium  are 
adherent  to  each .  other,  and  between  these  two  serous  layers  the 
phrenic  nerves  descend  to  the  diaphragm. 


THE  LUNGS. 

The  Root,  or  Pedicle,  of  the  Lung. — The  root  of  the  lung  is 
located  in  the  back  part  of  the  mediastinum  behind  the  ascending 
part  of  the  arch  of  the  aorta  and  above  the  base  of  the  heart.  That 
of  each  lung  is  composed  of  the  bronchus,  the  pulmonary  artery,  and 
the  pulmonary  veins,  together  with  lymphatics  (also  blood-vessels  for 
the  supply  of  lung  tissue  proper  and  plexuses  of  nerves). 

The  trachea  bifurcates  opposite  the  fifth  dorsal  vertebra,  and 
its  divisions,  the  bronchi,  are  directed  outward  and  downward  toward 
the  hilum  of  either  lung.  The  right  bronchus  is  more  horizontal, 
shorter,  and  of  wider  caliber  than  the  left,  and  its  lumen  is  more 
directly  continuous  with  that  of  the  trachea;  so  that  foreign  bodies 
dropped  into  the  trachea  are  more  apt  to  enter  the  right  than  the 
left  bronchus. 

The  pulmonary  artery  springs  from  the  upper  part  of  the  right 
ventricle,  and  at  its  origin  lies  in  front  of  the  root  of  the  aorta.  It  is 
a  short  trunk,  directed  upward  and  backward,  and  under  the  trans- 


300  THORAX. 

verse  part  of  the  arch  of  the  aorta  divides  into  the  right  and  left 
pulmonary.  These  pass  outward,  in  front  of  the  hronchi,  to  the  hilum 
of  either  lung.  At  the  hilum  the  pulmonary  arteries  are  located  upon 
a  higher  level  than  the  bronchi,  and  may  get  to  lie  partly  behind 
these  as  they  enter  the  lung. 

The  pulmonary  veins  are  short  trunks  which,  upon  leaving  the 
hilum  of  the  lung,  pass  transversely  inward  and  enter  the  correspond- 
ing side  of  the  left  auricle;  they  lie  some  little  distance  below  the 
level  of  the  bronchi  and  the  pulmonary  arteries. 

There  are  numerous  lymph  nodes  irregularly  arranged  about 
the  root  of  the  lung,  but  there  is  always  a  well-marked  group  below 
the  bifurcation  of  the  trachea. 

Over  the  root  of  the  left  lung,  arching  from  before  backward, 
is  the  arch  of  the  aorta.  The  vena  azygos  passes  over  the  root  of 
the  right  lung,  from  behind  forward,  and  enters  the  vena  cava  supe- 
rior, which  lies  just  in  front  of  the  root  of  the  right  lung,  upon  its 
posterior  aspect. 

The  Lung,  suspended  by  its  root,  occupies  the  pleural  cavity 
and  is  entirely  enveloped  by  the  visceral  layer  of  the  pleura.  At  the 
root  of  the  lung  this  visceral  layer  of  the  pleura  is  continuous  with 
the  mediastinal  part  of  the  parietal  pleura.  The  base  of  the  lung 
rests  upon  the  diaphragm;  its  apex  projects  into  the  root  of  the 
neck  for  a  distance  of  4  or  5  cm.  above  the  front  end  of  the  first 
rib.  In  the  natural  sitting  position  the  apex  of  the  lung  reaches  to 
a  point  about  3  cm.  above  the  clavicle. 

The  right  lung  consists  of  three  lobes,  the  left  of  two.  Each 
lung  upon  its  inner  surface  shows  a  depression  corresponding  to  the 
heart,  that  upon  the  left  lung  being  deeper  than  that  upon  the  right 
lung. 

The  lung  does  not  entirely  fill  the  pleural  cavity  except  above, 
where  the  apex  occupies  all  the  space  corresponding  to  the  dome  of 
the  pleura. 

Limits  op  the  Lungs. — The  posterior  border  of  each  lung  is 
found  alongside  the  vertebral  column.  The  anterior  border  of  the 
lung  corresponds  to  the  line  of  the  pleura  from  the  stemo-clavicular 
articulation  to  the  level  of  the  fourth  costal  cartilage.  The  anterior 
border  of  the  right  lung  continues  to  be  the  same  as  that  of  the  pleura 
down  to  the  level  of  the  sixth  costal  cartilage.  The  anterior  border 
of  the  left  lung,  at  the  junction  of  the  fourth  costal  cartilage  with 
the  sternum,  passes  almost  transversely  outward  behind  the  cartilage 


OrERATIONS  UPON  THE  BREAST.  301 

of  the  fourth  rib,  forming  the  upper  border  of  the  incisura  cardiaca, 
and  then,  midway  between  the  border  of  the  sternum  and  the  nipple, 
it  turns  downward  behind  the  fourth  intercostal  space  and  fifth  costal 
cartilage,  and  in  the  fifth  space  passes  sharply  inward,  forming  the 
lower  border  of  the  incisura  cardiaca. 

The  lower  border  of  either  lung  is  represented  by  a  line  which 
commences  at  the  junction  of  the  sixth  costal  cartilage  with  the 
sternum;  it  passes  downward  and  backward,  behind  the  sixth  costal 
cartilage,  and  crosses  the  seventh  rib  in  the  mammary  line;  from 
tiiis  point  the  line  passes  backward,  almost  transversely,  crossing  the 
eiglith  and  ninth  ribs  in  the  axillary  line,  the  tenth  rib  in  the  scap- 
ular line,  and  reaches  the  vertebral  column  upon  a  level  with  the 
articulation  of  the  eleventh  rib.  Although  the  line,  after  crossing 
the  seventh  rib  in  the  nuimmary  line,  is  continued  almost  trans- 
versely backward,  it  cuts  the  eighth,  ninth,  and  succeeding  lower 
ribs,  owing  to  the  obliquity  of  the  ribs. 

The  lower  edge  of  the  lung  does  not  reach  to  the  bottom  of 
the  pleural  cavity;  so  that  a  space  is  left  which  is  called  the  sinus 
phrenico-costalis.  This  space  commences  in  front,  and  gradually 
becomes  deeper;  upon  the  sides  it  is  deepest,  and  may  measure  up 
to  two  inches.  In  more  forcible  inspiration  this  space  is  partly 
obliterated  by  the  increased  expansion  of  the  lung. 

A  similar  pleural  space,  unoccupied  by  the  lung  (incisura  car- 
diaca), is  found  in  front  of  the  pericardium  and  heart,  corresponding 
to  the  fourth  intercostal  space  and  fifth  costal  cartilage,  to  the  left 
of  the  sternum. 

In  the  child  the  distance  between  the  lower  border  of  the  lung 
and  the  bottom  of  the  pleural  cavity  is  one-half  to  one  space  deeper 
than  described  above.  In  old  age  the  distance  between  the  lower 
border  of  the  lung  and  the  bottom  of  the  pleural  cavity  becomes 
one-half  to  one  space  shorter. 

Luschka  gives  the  depth  of  the  sinus  phrenico-costalis  as  fol- 
lows :  In  the  sternal,  parasternal,  and  mammary  lines,  3  cm. ;  in  the 
axillary  line,  6  cm.;   and  near  the  vertebra,  2.5  cm. 

OPERATIONS  UPON  THE  BREAST. 

Incisions  for  Abscess  of  the  Breast. — These  should  radiate  from 
the  region  of  the  nipple  toward  the  periphery  of  the  breast  in  order 
to  avoid,  as  far  as  possible,  cutting  across  the  milk-ducts,  which  all 


302  THORAX. 

converge  toward  the  nipple.  The  incisions  should  be  liberal,  and 
(Should  be  so  placed  as  to  allow  the  discharge  to  drain  through  the 
lower,  dependent  part  of  the  breast,  and,  if  necessary  in  order  to  ac- 
complish this,  one  or  more  counter-openings  may  be  made.  Liberal 
incisions  should  be  made  through  the  skin  and  fat,  and  the  abscess 
cavity  penetrated  with  closed  artery  forceps,  which  are  spread  apart 
as  they  are  withdrawn.  In  this  way  hemorrhage,  deep,  in  the  sub- 
stance of  the  gland  and  which  might  be  difficult  to  control,  is  less 
likely  to  occur.  The  finger  is  introduced  into  the  incision  and  any 
septa  which  might  obstruct  the  free  outflow  of  jous  l3roken  down. 

Extirpation  of  Tumors  Out  of  the  Substance  of  the  Mammary 
Gland  (Fibroids,  for  Example). — An  incision  is  made  corresponding  in 
length  to  the  size  of  the  tumor  and  radiating  from  the  areola  toward 
the  periphery  of  the  breast. 

These  tumors  are  usually  encapsulated  and  well  defined,  and  can 
be  dissected  out  with  blunt-pointed  scissors  or  may,  at  times,  be 
enucleated  by  blunt  dissection  with  the  finger. 

Amputation  of  the  Breast  (Halsted-Meyer) . — The  breast,  together 
with  the  pectoralis  major  and  minor  muscles  and  the  glands  and 
connective  tissue  of  the  axilla,  must  all  be  removed  in  one  single  mass 
and  without  cutting  into  the  diseased  tissue.  The  patient  lies  upon  the 
back  with  the  arm  abducted  and  supported  by  an  assistant. 

An  incision  is  made  through  the  healthy  skin  and  fat,  elliptical 
and  circumscribing  the  tumor;  from  the  upper  end  of  the  ellipse  the 
incision  should  be  continued  along  the  edge  of  the  pectoralis  major  to  a 
point  upon  the  upper  part  of  the  arm  a  little  beyond  (below)  the 
attachment  of  the  tendon  of  this  muscle  to  the  humerus.  Although  it 
is  desirable  to  bring  the  edges  of  the  wound  together  with  sutures  at 
the  end  of  the  operation,  yet  one  should  not,  on  this  account,  take  any 
chance  in  leaving  suspicious-looking  integimient,  because  if  we  are 
unable  to  close  the  wound  with  sutures  we  can  cover  any  remaining  raw 
space  with  skin  grafts. 

To  this  first  incision  a  second  is  added  which  runs  obliquely  from 
the  junction  of  the  middle  and  outer  thirds  of  the  clavicle  down  into 
the  upper  border  of  the  elliptical  incision.  The  corners  of  the  skin-flaps 
which  are  thus  marked  out  are  seized  with  the  fingers  and,  including 
but  little  of  the  fat  layer,  are  dissected  away  from  the  breast  (tumor) 
and  from  the  underlying  surface  of  the  muscles,  etc.,  upward,  toward 
the  clavicle;  inward,  toward  the  sternum,  and  outward,  toward  the 
axilla.     In  this  way  we  expose  the  sternal  and  clavicular  portions  and 


OPERATIONS  UPON  THE  BREAST. 


503 


the  tendon  of  the  pectoralis  major  muscle.  In  the  space  between  the 
upper  border  of  the  pectoralis  major  and  tlie  deltoid  the  cephalic  vein 
and  the  descending  branch  of  the  acromio-thoracic  artery  are  foimd. 
Externally  corresponding  to  the  line  of  reflection  of  the  external  flap 
the  edge  of  the  latissimus  dorsi  is  exposed. 

The  tendon  of  the  pectoralis  major  is  hooked  up  upon  the  finger 
and  divided  close  to  its  attachment  to  the  humerus,  and  then,  following 
along  the  upper  border  of  this  muscle,  between  it  and  the  edge  of  the 


Pig.  150.— Amputation    of    the    Breast.      Halsted-Meyer    incision    for    amputation 
of  the  breast  and  to  clean  out  the  axiUa. 

deltoid  as  far  as  the  clavicle,  this  muscle  (pectoralis  major)  is  cut  away 
from  its  attachment  to  the  clavicle  and  reflected  downward,  thus 
exposing  the  next  underlying  layer,  or  "etage,"  which  consists  of 
the  pectoralis  minor  muscle  covered  by  its  fascia  and  some  loose  con- 
nective tissue  and  the  costo-coracoid  membrane. 

Frequently  that  portion  of  the  pectoralis  major  which  arises  from 
the  clavicle  can  be  saved.  This  will  add  much  to  the  usefulness  of  the 
arm  after  the  operation.  A  distinct  groove  is  seen  between  that  por- 
tion of  the  pectoralis  major  which  arises  from  the  clavicle  and  that 
which  arises  from  the  chest-wall.  If  it  is  desifed  to  save  the  clavicu- 
lar portion  of  the  muscle  the  finger  is  introduced  into  the  groove  be- 
tween these  two  portions  and  that  part  of  the  tendon  which  corresponds 


304  THORAX. 

to  the  pectoral  origin  of  the  muscle  only  is  hooked  up  and  divided  close 
to  its  attachment  to  the  humerus  as  already  described. 

The  fascia  that  covers  the  pectoralis  minor  is  continued  upward 
from  the  inner  border  of  the  muscle  as  the  costo-coracoid  membrane 
and  is  attached  to  the  first  rib  and  under  surface  of  the  clavicle,  thus 
covering  in  the  structures  of  the  infraclavicular  region — the  axillary 
vessels,  etc.  The  costo-coracoid  membrane  is  perforated  by  the  ceph- 
alic vein,  the  anterior  thoracic  nerves  which  supply  the  pectoralis 
major  and  minor,  etc. 

The  fascia  that  covers  the  tendon  of  the  pectoralis  minor  muscle 
and  which  is  continued  upward  and  inward  beyond  the  inner  edge  of  the 
tendon  as  the  costo-coracoid  membrane,  is  incised  over  the  tendon  and 
is  cut  away  from  its  attachment  to  the  clavicle.  The  finger  is  hooked 
around  the  tendon  of  the  pectoralis  minor  and  it  is  divided  close  to  its 
attachment  to  the  coracoid  process.  The  bundle  of  important  vas- 
cular and  nervous  structures  in  the  axillary  space  is  thus  uncovered. 
The  large,  thin-walled  axillary  vein  is  promptly  recognized.  The 
axillary  artery  is  concealed  underneath  the  vein.  A  chain  of  lymph- 
atic vessels  and  nodes  and  connective  tissue  and  fat  follows  the  course 
of  the  vein,  and  is  in  close  relationship  with  its  wall.  The  three  cords 
of  the  brachial  plexus  are  situated,  one  above,  another  behind,  and  the 
third  below,  the  axillary  artery.  In  the  upper  inner  part  of  the  axil- 
lary space,  the  three  cords  of  the  brachial  plexus  lie  all  above  the 
artery.  These  structures  are  all  collected  in  a  bundle  and  may  be  fol- 
lowed upward  and  inward  through  the  axillary  space  and  under  the 
clavicle,  beyond  the  first  rib,  into  the  root  of  the  neck.  The  sub- 
scapular vein,  the  largest  and  most  prominent  branch  of  the  axillary 
vein,  accompanied  by  the  corresponding  branch  of  the  axillary  artery, 
may  also  be  promptly  recognized  in  the  axillary  space.  These  vessels 
are  accompanied  by  the  subscapular  nerve,  which  may  be  identified  by 
pinching  it  purposely  or  accidentally  with  the  forceps.  When  the 
nerve  is  touched  or  pinched,  the  latissimus  dorsi  contracts. 

Commencing  as  high  up  as  possible,  the  space  beneath  the  clavicle 
being  made  more  accessible  by  elevating  the  shoulder,  all  the  fat  and 
connective  tissue  are  cleaned  away  from  the  vessels,  ligating  all 
branches  as  they  are  met  with  and  working  outward  and  downward 
along  the  course  of  the  axillary  vein.  After  the  space  beneath  and 
above  the  clavicle  has  b'een  thoroughly  cleared  of  all  fat  and  connective 
tissue,  the  dissection  is  continued  down  along  the  course  of  the  axillary 
vessels  and  nerves,  working  pretty  close  to  the  wall  of  the  vein  all  the 


OPERATIONS  UPOX  THE  BREAST.  305 

time,  as  far  as  the  attachment  of  the  tendon  of  the  pectoralis  major  to 
the  humerus.  This  dissection  must  be  thorough  and  carried  out  with 
great  care  so  as  not  to  wound  the  axillary  vein.  If  the  vein  should 
be  accidentally  wounded  an  effort  must  be  made  to  close  the  opening. 
If  the  opening  is  small  this  may  be  done  with  a  side  ligature  carefully 
applied;  if  larger,  the  opening  may  be  closed  with  a  continous  suture, 
using  the  finest  silk  smeared  with  vaselin,  and  the  finest  straight  needle. 
The  method  of  closure  is  quite  similar  to  that  described  on  page  28. 
The  circulation  must  be  interrupted  during  the  application  of  the 
suture  by  apph'ing  two  rubber-sheathed  Crile  clamps  to  the  vein,  one 
above  and  the  other  below  the  opening.  The  tissue  which  is  removed 
from  the  axilla  should  not  be  taken  away  piecemeal,  but  should  be  dis- 
sected free  from  the  vessels,  etc.,  in  one  continuous  mass  and  allowed 
to  remain  connected  with  the  general  tumor  mass. 

Xow,  from  the  posterior  wall  of  the  axilla  and  from  the  side  of 
the  chest,  all  the  fat  and  connective  tissue  and  lymphatic  tissue  are 
cleared,  working  from  behind  forward  and  laying  bare,  behind,  the 
anterior  surface  of  the  latissimus  dorsi,  subscapularis,  and  teres  ma- 
jor muscles  (posterior  wall  of  the  axillary  space)  and,  upon  the  side 
of  the  thorax,  the  ribs  and  serratus  magnus  muscle.  Upon  the  poste- 
rior wall  of  the  axilla  the  subscapular  nerve,  in  company  with  the  sub- 
scapular vessels,  is  encountered.  This  nerve  supplies  the  latissimus 
dorsi  and  should  be  saved,  if  possible,  and  likewise  the  vessels,  if  they 
have  not  already  been  cut. 

Upon  the  side  of  the  chest  we  meet  the  long  thoracic  vessels  and 
the  long  thoracic  nerve ;  if  the  nerve  is  recognized  it  may  be  possible  to 
avoid  cutting  it.     It  supplys  the  serratus  magnus. 

The  whole  mass — which  consists  of  the  breast  (tumor),  pectoral 
muscles  (major  and  minor),  axillary  contents,  etc. — is  now  grasped 
by  the  operator  and  lifted  away  from  the  chest  wall  when  the  attach- 
ments of  the  pectoral  muscles  to  the  ribs  and  sternum  are  cut,  and 
then,  the  mass  being  gradually  turned  out  of  the  wound,  the  extirpa- 
tion is  completed  and  the  bare  wall  of  the  chest,  together  with  the 
axillary  vessels  and  the  nerves  which  accompany  them,  is  exposed  to 
view.  When  the  mass  is  lifted  away  from  the  chest  wall,  the  perfo- 
rating vessels — branches  of  the  intercostals  and  the  internal  mam- 
mar}^ — may  be  seen  as  they  enter  the  posterior  surface  of  the  pec- 
toralis major  and  care  should  be  taken  not  to  tear  these  or  cut  them 
too  close  to  the  surface  of  the  chest  wall,  as  it  might  then  be  difficult 
to  clamp  and  tie  them.    They  may  often  be  secured  with  clamps  before 


306  THORAX. 

they  are  cut.  All  hemorrhage  must  positively  be  controlled  before 
proceeding  to  close  the  wound. 

The  edges  of  the  wound  are  brought  together  by  suture,  and  if 
too  much  integument  has  not  been  removed  the  wound  may  be  thus 
closed  entirely.  Special  care  is  taken  to  close  in  the  axillary  space  by 
bringing  the  little  triangular  flap  which  corresponds  to  the  outer  edge 
of  the  incision  up  to  the  upper  margin  of  the  incision  and  suturing  it 
in  this  position.  Interruj)ted  sutures  of  silkworm  gut  are  used  for 
closing  the  wound.  Occasional  tension  sutures  may  be  necessary.  If 
there  is  any  raw  space  remaining,  it  may  be  covered  with  skin-grafts 
applied  at  once.  A  cigarette  drain  is  placed  in  the  axilla.  A  little 
stab-hole  is  made  for  this  purpose  in  the  lower  part  of  the  little  external 
triangular  flap.  The  drain  may  be  removed  on  the  sixth  or  seventh 
day  when  the  first  dressing  is  made.  If  a  portion  of  the  wound  has 
been  covered  by  skin  grafting  the  dressing  must  be  changed  on  the 
third  day. 

One  should  minimize  the  loss  of  blood  as  much  as  possible  during 
the  course  of  the  operation,  clamping  vessels  before  or  immediately 
after  they  are  cut. 

Skin  Grafting,  Thiersch. — Very  thin  strips  of  skin,  about  one 
inch  wide  and  one  to  several  inches  long,  are  planted  upon  the  surface 
which  is  to  be  covered.  If  this  surface  is  old,  it  must  be  curetted  or 
the  granulations  rubbed  off  with  a  gauze  wipe.  If  the  surface  is  dense 
and  hard,  as  is  sometimes  found  in  old  chronic  ulcer  of  the  leg,  it  will 
be  necessary  to  excise  it.  It  is  necessary  to  have  a  good  vascular  sur- 
face upon  which  to  place  the  grafts,  but  all  active  hemorrhage  and 
oozing  must  be  checked  by  ligatures  or  by  pressure  with  a  gauze  pad 
before  applying  the  grafts. 

The  skin-grafts  are  usually  taken  from  the  anterior  surface  of  the 
arm  or  thigh,  and  preferably  from  the  patient  himself.  Grafts  may 
also  be  taken  from  another  person.  The  part  from  which  the  grafts 
are  to  be  taken  is  disinfected  in  the  usual  manner,  washed  with  soap 
and  water,  followed  by  dilute  alcohol,  and  then  washed  with  normal 
salt  solution  and  covered  with  a  towel  wet  in  the  salt  solution.  The 
skin  is  shaved  ofE"  in  very  thin  strips.  The  grafts  are  cut  with  a 
steady  back  and  forward  sawing  motion,  using  a  very  sharp  razor  for 
this  purpose.  The  surface  from  which  the  grafts  are  taken  must  be 
held  taut — ^upon  the  stretch — by  the  operator  and  his  assistant  while 
the  grafts  are  being  cut.  The  skin  and  the  razor  are  kept  moist 
while  the  grafts  are  being  cut.     This  is  done  by  the  assistant  squeezing 


OPERATIONS  UPON  THE  HEART.  307 

a  gauze  pad  wet  in  salt  solution.  The  salt  solution  is  allowed  to  fall 
on  the  razor-blade  drop  by  drop  while  the  grafts  are  being  cut.  Each 
individual  graft  is  immediately  carried  upon  the  razor-blade  to  the 
surface  where  it  is  to  be  deposited.  The  graft  is  transferred  from 
the  razor-blade  to  the  raw  surface  by  fixing  the  end  of  the  graft  upon 
the  wound  surface  with  a  probe  and  then  sliding  the  razor-blade  from 
underneath  it.  The  thin  layer  of  skin  is  spread  out  upon  the  wound 
surface  as  it  is  delivered  off  the  razor-blade^,  care  being  taken  that  the 
edges  are  not  turned  under.  The  grafts  are  placed  side  by  side, 
leaving  a  narrow  interval  between  them.  After  the  grafts  have  all 
been  placed  upon  the  raw  surface  they  are  covered  over  with  strips  of 
rubber  tissue.  The  rubber-tissue  strips  are  one-half  to  three-quarters 
inch  wide,  and  arc  placed  so  that  they  overlap  one  another  slightly  like 
the  shingles  on  a  roof.  A  dry  dressing  of  folded  gauze  pads  is  ap- 
plied. Care  is  taken  not  to  rub  or  displace  the  grafts  while  the  dress- 
ings and  bandages  are  being  applied. 

The  raw  surface  which  is  left  where  the  grafts  have  been  taken 
is  also  covered  with  strips  of  rubber  tissue  and  a  dry  dressing  applied. 

ligation  of  the  Intercostal  Artery.- — Each  intercostal  artery  is 
situated,  together  with  the  intercostal  vein  and  nerve,  beneath  the 
lower  border  of  the  corresponding  rib.  These  vessels  may  be  injured 
in  stab  wounds,  etc. 

At  times  it  becomes  necessary  to  resect  a  part  of  the  rib  sub- 
periosteally  in  order  to  get  at  the  bleeding  points.  It  is  necessary 
to  tie  both  ends  of  the  vessel. 

Ligation  of  the  Internal  Mammary  Artery. — To  secure  tliis  vessel 
one  must  resect  the  costal  cartilage  of  the  second  or  third  rib  close  to 
the  sternum  or  the  vessel  may  be  ligated  through  a  transverse  incision 
placed  midway  between  the  contiguous  cartilages  and  close  to  the 
sternum  in  the  third  intercostal  space.  The  vessel  descends  upon  the 
posterior  surface  of  the  anterior  chest  wall,  its  vein  alongside  of  it;  it 
is  accompanied  also  by  a  chain  of  lymphatic  nodes. 

OPERATIONS  UPON  THE  HEART. 

Paracentesis  Pericardii. — Tapping  the  pericardium.  This  opera- 
tion may  be  resorted  to  when  an  effusion  resists  other  measures  of  treat- 
ment or  when  it  is  causing  urgent  symptoms  of  cardiac  distress.  The 
puncture  is  made,  as  -a  rule,  in  the  fifth  or  sixth  left  intercostal  space 
close  to  the  edge  of  the  sternum.  By  inserting  the  needle  close  to  the 
sternum  the  internal  mammary  vessels  are  avoided ;  in  the  sixth  inter- 


308  THORAX. 

space  there  is  still  less  likelihood  of  meeting  the  anterior  free  edge  of 
the  pleura  than  in  the  fifth;  therefore  the  sixth  space  is  rather  pref- 
erable except  that  occasionally  it  is  inconveniently  narrow. 

A  short  vertical  incision  is  made  through  the  skin  at  the  left  edge 
of  the  sternum  and  corresponding  to  the  fifth  or  sixth  intercostal 
space. 

For  the  purpose  of  evacuation  a  trocar  and  cannula  may  be  used.- 
If  the  sixth  space  is  selected  the  instrument  is  pushed  through  the 
intercostal  structures  in  a  direction  backward  and  inward.  If  the 
puncture  is  made  in  the  fifth  space  the  needle  is  entered  close  to  the 
edge  of  the  sternum  and  near  the  upper  border  of  the  sixth  costal 
cartilage  and  is  pushed  at  first  directly  backward  to  a  depth  of  about 
one-third  inch — the  thickness  of  the  sternum — and  then  inward 
behind  and  close  to  the  posterior  surface  of  the  sternum  for  a  distance 
of  about  one-half  inch  in  order  to  make  certain  of  clearing  the  edge  of 
the  pleura  and  then,  finally,  backward  and  somewhat  downward  and 
inward  into  the  distended  pericardial  sac.  While  the  instrument  is 
being  introduced  it  should  be  guarded  with  the  finger  to  prevent  its 
abruptly  entering  the  chest.  Fluid  may  be  evacuated  with  or  without 
aspiration,  depending  upon  the  facility  with  which  it  escapes.  As 
much  as  a  pint  has  been  withdrawn  at  a  single  operation.  The  small 
incision  in  the  skin  may  be  closed  with  a  single  suture. 

Pericardiotomy. — Incision  of  the  pericardial  sac  in  order  to  estab- 
lish drainage;  for  empyema;  for  the  purpose  of  exploration  in  cases 
of  suspected  wound  of  the  heart.  The  fifth  or  sixth  costal  cartilage, 
preferably  the  sixth,  is  resected. 

An  incision  corresponding  to  the  sixth  left  costal  cartilage  is 
made.  It  commences  at  the  edge  of  the  sternum  and  exposes  the 
cartilage  for  its  whole  length.  The  soft  parts  are  detached  with  the 
elevator  and  the  cartilage  resected  with  the  bone-forceps.  The  struc- 
tures corresponding  to  the  posterior  surface  of  the  cartilage  that  has 
been  resected,  are  divided  with  the  knife  and  the  internal  mammary 
vessels  exposed.  These  vessels  are  found  about  one-half  inch  distant 
from  the  border  of  the  sternum.  They  are  ligated  double  and  divided 
between  the  ligatures.  The  triangularis  sterni — a  flat,  muscular  layer 
that  is  spread  out  upon  the  posterior  surface  of  the  costal  cartilages, 
etc.,  between  these  and  the  parietal  layer  of  the  pleura — is  exposed  to 
view.  This  muscular  layer  is  incised  and  its  edge  retracted  outward. 
The  lower  anterior  edge  of  the  pleura  is  then  recognized  and  is  care- 
fully separated  from  the  pericardial  sac  and  also  retracted  outward. 


OPERATIONS  UPON  THE  HEART.  309 

The  line  of  separation  between  the  edge  of  the  pleura  and  the  peri- 
cardial sac  is  usually  indicated  by  a  small  pad  of  fat.  Care  is  exer- 
cised not  to  incise  the  pleural  sac  in  this  step  of  the  operation. 

The  pericardium  is  recognized  as  a  dense,  whitish,  fibrous  sac. 
It  is  picked  up  with  two  toothed  forceps  and  divided  between  these. 
If  it  is  desired  to  keep  the  sac  open  for  the  purpose  of  drainage  the 
edges  of  the  opening  which  has  been  made  are  sutured  to  the  edges  of 
the  deeper  layers  in  the  skin  incision  with  several  interrupted  sutures. 
A  soft-rubber  tube  or  a  cigarette  drain  is  introduced.  The  skin  in- 
cision is  closed  in  part. 

Pericardiorrhaphy. — Suture  of  the  pericardium.  After  the  peri- 
cardial sac  has  been  exposed  the  edges  of  the  opening  or  wound  in  it 
are  brought  together  with  silk  or  catgut  sutures  in  such  fashion  that 
the  edges  are  everted  and  the  serous  surfaces  are  apposed.  The  skin 
incision  should  be  left  open  in  part  and  drained. 

Cardiorrhaphy. — Suture  of  wounds  of  the  heart.  All  wounds  of 
the  heart  are  not  necessarily  fatal.  In  many  cases  the  wound  may  be 
closed  and  the  hemorrhage  checked  by  suture.  Operative  interference 
must,  however,  be  prompt  to  be  effectual.  Death  ensues  in  wounds  of 
the  heart  promptly  as  a  direct  result  of  the  great  quantity  of  blood 
lost  or  rather  more  slowly  as  a  result  of  compression  of  the  heart,  espe- 
cially of  the  thin-walled  auricles  and  the  veins  that  empty  into  them, 
by  the  blood  that  has  escaped  through  the  wound  in  the  heart  filling 
and  distending  the  pericardial  sac — heart  tamponade.  If  the  blood 
cannot  escape  from  the  pericardial  sac  it  may  collect  in  such  great 
quantity  and  under  such  great  pressure  that  the  thin-walled  auricles 
and  the  veins  that  enter  them  are  compressed  to  such  a  degree  that  the 
circulation  becomes  seriously  impeded  or  entirely  interrupted — the 
blood  cannot  enter  the  auricles  and  is  dammed  back  in  the  venae  cavse 
and  pulmonary  veins.  Under  these  circumstances,  by  simply  enlarging 
or  making  an  opening  in  the  pericardial  sac,  thus  giving  vent  to  the 
blood  that  is  confined  within  the  pericardial  sac,  the  pressure  upon  the 
heart  is  relieved  and  oftentimes  the  heart  will  resume  its  pulsation  even 
after  it  had  almost  or  entirely  ceased. 

Wounds  of  the  heart  are  usually  marked  by  an  extreme  degree  of 
shock — the  patient  is  usually  unconscious  from  loss  of  blood  and  shock. 
Blood  may  be  escaping  in  great  quantity  from  a  wound  in  the  chest 
or  there  may  be  but  little  or  no  external  hemorrhage.  The  pulse  is 
irregular,  rapid,  and  feeble.  If  the  finger  is  placed  in  the  wound  it 
may  lead  down  into  the  pericardial  sac,  palpate  the  heart,  and  its 


310  THORAX. 

■vvitlidraAval  may  be  accompanied  with  a  great  gush  of  blood.  If  the 
blood  remains  imprisoned  in  the  pericardial  sac  there  will  be  an  in- 
creased area  of  cardiac  dullness,  the  heart  sounds  are  distant  and  in- 
distinct or  inaudible,  and  signs  of  heart  tamponade  will  be  present. 
These  are  c3^anosis,  distension  of  the  superficial  veins  of  the  neck,  face, 
etc.,  prominent  bulging  of  external  jugulars,  dyspnoea,  and  labored 
breathing.  These  signs  are  accompanied  by  a  progressive  fall  in  blood- 
pressure  with  corresponding  rapid,  feeble  radial  pulse,  which  gradually 
becomes  extinct.  If  the  finger  is  introduced  into  the  wound  it  may 
be-  followed  by  a  gush  of  blood  which  may  relieve  the  symptoms.  If 
the  pleural  cavity  has  been  opened  there  will  be  pneumothorax  or  the 
pleural  cavity  may  contain  a  large  quantity  of  blood.  In  cases  of 
doubt  with  a  wound  in  the  prsecordial  region  and  excessive  hemor- 
rhage, or  without  external  hemorrhage  and  symptoms  of  heart  tam- 
ponade, an  exploratory  pericardiotomy  is  surely  indicated. 

Patients  with  heart  wounds  are  usually  in  extreme  collapse  from 
shock  and  hemorrhage  and  in  many  cases  unconscious,  so  that  little  or 
no  anaesthetic  is  required.  The  operation  may  be  commenced  without 
any  anesthetic,  and  if  an  ansesthetic  becomes  necessary  during  the 
pi'ogress  of  the  operation,  ether,  by  the  drop  method,  is  most  satis- 
factory.    The  patient  must  be  kept  warm. 

It  may  be  imperative,  on  account  of  sjanptoms  of  heart  compres- 
sion, to  gain  access  to  the  pericardial  sac  as  promptly  as  possible;  and 
then,  after  evacuating  the  blood  and  according  to  the  conditions  that 
are  found,  the  opening  may  be  enlarged  as  necessary.  If  it  is  apparent 
that  the  pleural  cavity  has  not  been  opened  by  the  original  wound, 
stab,  etc.,  we  should  employ  a  method  of  operating  that  offers  the  least 
chance  of  opening  the  pleural  cavity.  If  the  pleural  cavity  has  already 
been  opened  the  necessity  for  avoiding  this  accident  does  not  exist  and 
the  operation  becomes  much  simpler. 

With  the  Pleuka  Apparently  Unopened. — An  incision  is 
made  from  the  level  of  the  third  costal  cartilage  downward  a  little  to 
the  left  of  the  middle  line  of  the  sternum  as  far  as  the  junction  of  the 
sixth  costal  cartilage  with  the  sternum,  and  from  this  point  another 
incision  is  carried  downward  and  outward  alorg  the  cartilage  of  the 
sixth  rib.  From  the  upper  end  of  the  vertical  incision  another  is 
carried  outward  upon  the  third'  rib,  nearer  its  upper  border.  This 
last  incision  penetrates  through  the  pectoralis  muscle  down  to  the  sur- 
face of  the  cartilage.  In  some  cases  it  will  not  be  necessary  to  resect 
higher  than  the  fourth  costal  cartilage;  therefore  this  upper  incision 


OPERATIOXS  UPON  THE  HEART.  311 

may  be  left  1111111  later,  placing  it  upon  the  third  or  fourth  costal  car- 
tilage as  may  be  required.  The  soft  parts  are  carefully  detached  from 
the  sixth  cartilage,  in  front,  along  the  upper  and  lower  borders  and 
behind,  with  the  elevator  and  the  cartilage  then  resected  with  the  bone 
forceps.  The  internal  mammary  artery  and  vein  are  seen  about  one- 
half  inch  from  the  edge  of  the  sternum.  The  vessels  are  surrounded 
with  a  ligature,  tied  double  and  divided.  Beneath  the  vessels  is  a  thin 
sheet  of  muscle,  the  triangularis  sterni.  This  muscle  layer  is  incised 
close  to  the  sternum.  The  edge  of  the  muscle,  together  with  the  free 
edge  of  the  pleura  which  is  usually  adherent  to  the  under  surface  of 
the  muscle,  is  separated  and  peeled  outward  away  from  the  dense 
whitish,  fibrous  pericardial  sac,  leaving  the  latter  thus  exposed.  The 
space  or  line  of  separation  where  the  free  edge  of  the  pleura  is  in 
relation  with  the  pericardial  sac  is  usually  indicated  by  a  small  wad 
of  fat.  Blood  may  be  seen  issuing  from  a  wound  in  the  pericardial 
sac  or  it  may  be  necessary  to  enlarge  or  to  make  an  opening  in  the 
sac  to  permit  the  blood  to  escape  and  relieve  the  heart  from  com- 
pression— heart  tamponade. 

In  some  cases  sufficient  exposure  may  be  obtained  with  this  in- 
cision to  treat  a  wound  in  the  heart,  especially  if  the  cartilage  above, 
the  fifth,  is  cut  away  from  its  attachment  to  the  sternum  and  tractors 
are  introduced  and  the  edges  of  the  wound — cartilages — pulled 
strongly  apart.  As  a  rule,  however,  it  is  necessary  to  expose  the 
heart  more  freely.  For  this  purpose  the  soft  parts,  pleura  and  tri- 
angularis sterni  muscle,  are  peeled  away,  in  an  outward  direction,  from 
the  under  surface  of  the  fifth  costal  cartilage  and  this  cartilage  then 
cut  away  with  the  bone-forceps  from  its  attachment  to  the  edge  of  the 
sternum.  While  the  flap  is  lifted  forcibly  the  soft  parts  are  separated 
in  a  similar  manner  from  the  under  surface  of  the  fourth  costal  car- 
tilage and  the  cartilage  cut  away  in  like  manner  from  its  attachment 
to  the  sternum.  If  necessary  the  third  cartilage  may  be  treated  in  the 
same  way.  The  soft  parts,  intercostal  muscles,  etc.,  are  detached  from 
the  upper  border  of  the  third  costal  cartilage  through  the  upper,  trans- 
verse, incision  that  was  made  along  the  line  of  this  rib,  Avith  the 
periosteum  elevator.  As  already  mentioned,  it  may  not  be  necessary 
to  resect  the  cartilages  higher  than  the  fourth.  The  chondroplastic 
flap  which  is  thus  marked  out  consists  of  the  fifth,  fourth,  and  third 
costal  cartilages — the  sixth  has  been  resected — and  the  corresponding 
intercostal  muscles,  integument,  etc.  According  as  the  flap  is  lifted, 
the  soft  parts,  pleura  and  triangularis  sterni  muscle,  are  cautiously 


312 


THORAX. 


peeled  away  from  its  under  surface  and  the  flap  is  finally  forcibly  bent 
along  its  outer  border,  base^,  breaking  the  ribs  at  their  chondrocostal 
junction  so  that  the  flap  may  be  reflected  and  turned  down  flat  upon  the 
chest  wall.  After  the  flap  has  been  thus  reflected  and  the  pericardial 
sac  exposed  and  incised,  free  access  may  be  had  to  the  heart  from  its 
base  to  its  apex.  The  pleura  may  already  have  been  punctured  or  it 
may  be  torn  during  the  reflection  of  the  flap  with  a  resulting  pneumo- 


Fig.  151.— Posterior  Aspect   of   Sternum   and   Ribs;    Triangularis    Sterni    Muscle; 
Internal  Mammary  Artery  and  Vein. 


thorax.  The  edges  of  a  small  opening  in  the  pleura  may  be  caught 
with  the  artery  forceps  or  the  opening  may  be  covered  over  with  a 
gauze  wipe  to  prevent  the  entrance  and  exit  of  air,  A  large  rent  in 
the  pleura  with  collapse  of  the  lung  may  be  disregarded  until  the  heart 
wound  has  been  sutured. 

It  may  be  necessary  occasionally  to  gain  still  more  room.  For 
this  purpose  an  osteoplastic  flap  may  be  taken  from  the  sternum  and 
turned  over  toward  the  right  side.    The  soft  parts,  fascia  and  pleura. 


OPERATIONS  UPON  THE  HEART. 


313 


are  detached  from  the  under  surface  of  the  sternum  and  the  sternum 
then  cut  across  above  and  below,  with  the  bone-forceps.  The  osteo- 
plastic flap  is  bent  over  toward  the  right  side,  fracturing  the  ribs  and 
making  a  hinge  at  the  right  chondrosternal  border. 

The  pericardial  sac  is  freely  opened  and  blood  and  clots  cleared 
out.  The  heart  may  be  seen  beating  tumultuously  in  a  pool  of  frothy 
blood.     The  heart  is  picked  up  in  the  hollow  of  the  left  hand  for  ex- 


Fig.  152. — Incision  in  Soft  Parts  for  Exposure  of  Heart. 


amination.  The  index  and  middle  fingers  are  inserted  behind  the 
heart,  which  is  steadied  with  the  thumb  anteriorly.  The  heart  may  be 
lifted  partly  out  of  the  sac  or  twisted  slightly  upon  its  long  axis  in 
order  to  examine  its  posterior  aspect.  Blood  may  be  spurting  furi- 
ously from  the  wound  in  the  heart  with  each  beat.  The  hemorrhage 
may  be  controlled  momentarily  by  placing  the  finger  over  the  wound 
or  into  the  wound,  or  it  may  be  necessary  to  compress  the  right  auricle 
by  grasping  it  between  two  fingers  of  the  left  hand  and  making  pres- 
sure with  the  thumb  anteriorly.     This  may  be  continued  for  a  few 


314  THORAX. 

seconds — long  enough  to  get  in  one  suture  to,  at  least,  partly  control 
the  hemorrhage.  If  the  heart  has  stopped  beating  gentle  massage  and 
rhythmic  compression  may  cause  it  to  resume  its  pulsation.  The  first 
suture  is  passed  across  the  middle  of  the  wound.  It  takes  a  good 
broad  bite,  JDut  does  not  penetrate.  In  wounds  of  the  thin-walled 
auricle  it  may  be  difficult  not  to  penetrate.  Fine  silk,  passed  in  a  thin, 
smooth  curved  needle  is  used  for  sutures.  The  effort  may  be  made  to 
pass  and  tie  the  sutures  during  diastole.  This  will  be  difficult  or  im- 
possible owing  to  the  rapid,  irregular  beating  of  the  heart.  After 
the  first  suture  has  been  passed  and  tied  the  ends  are  left  long  to  use  as 
tractors  to  steady  the  heart  and  facilitate  the  introduction  of  the  suc- 
ceeding sutures.  The  sutures  are  placed  sufficiently  close  together  to 
completely  control  the  hemorrhage.  A  severed  coronary  artery  must 
be  ligated. 

The  opening  in  the  pericardial  sac  is  closed  with  a  sufficient  num- 
ber of  interrupted  sutures  of  chromic  catgut,  except  in  the  lower  part 
where  a  small  opening  is  left  for  the  introduction  of  a  cigarette  drain. 
If  the  pleura  has  been  opened  it  will  be  necessary  to  drain  the  pleural 
cavity.  The  pericardial  and  pleural  cavities  should  be  drained  inde- 
pendently of  each  other — ^two  separate  drains.  The  pleural  cavity 
may  be  drained  through  a  small  stab  hole  which  is  made  in  the  eighth 
or  ninth  intercostal  space  near  the  axillary  line. 

The  flap  is  replaced  and  sutured  in  position  with  interrupted 
sutures  of  silkworm  gut. 

The  drains  may  be  removed  at  the  end  of  forty-eight  hours  and 
need  not  be  replaced  if  the  wound  is  clean. 

Occasionally  in  wounds  of  the  heart  the  wound  of  entrance  is 
found  upon  the  right  side  of  the  sternum.  Under  these  circumstances, 
and  especially  if  the  right  pleural  cavity  has  been  opened,  pneumo- 
thorax, it  would  be  extremely  hazardous  to  proceed  to  expose  the  heart 
from  the  left  side  of  the  sternum  as  described  above  for  fear  of  opening 
the  pleural  cavity  in  this  side  (where  the- right  pleural  cavity  has  prob- 
ably or  certainly  already  been  opened),  with  a  resulting  double  pneumo- 
thorax and  collapse  of  both  lungs.  In  these  cases  it  would  be  wise  to 
expose  the  heart  by  making  an  osteoplastic  resection  of  the  sternum, 
turning  the  flap  over  toward  the  left  so  that  the  base,  hinge,  cor- 
responds to  the  left  sternochondral  Junction. 

If  the  heart  is  exposed  under  intratracheal  insufflation  anaesthesia 
the  lungs  can  be  inflated  so  as  to  completely  fill  the  chest  cavity  before 
closing  by  increasing  the  intrapulmonary  pressure.     This  can  be  done 


OPERATIONS  UPON  THE  PLEURA.  315 

by  compressing  the  larynx  about  the  intratraclieal  tube.  This  plan  of 
ana?sthesia  would,,  no  doubt,  be  of  the  greatest  advantage  in  operations 
upon  the  heart  if  time  and  conditions  would  permit  the  introduction  of 
the  intratracheal  tube.  It  would  obviate  the  danger  that  would  result 
from  pneumothorax,  especially  if  both  pleural  cavities  were  opened 
during  the  course  of  the  operation,  and  would  permit  of  complete 
closure  of  the  pleural  cavity  without  drainage  in  many,  if  not  all.  cases. 
Spaxgaro's  Ixcisiox. — If  it  is  apparent  that  the  pleural  cavity 
has  been  opened  (and  this  is  the  fact  in  the  majority  of  cases  of  wounds 
of  the  heart)  and  if,  therefore,  the  necessity  of  avoiding  accidental  open- 
ing of  this  cavity  during  the  course  of  the  operation  does  not  exist,  then 
assuredly  the  quickest  and  most  satisfactory  way  of  gaining  access  to 
the  heart  is  by  means  of  the  incision  described  by  Spangaro — through 
the  fifth  intercostal  space.  The  original  wound  may  be  utilized,  if  in 
the  foui-th  or  fifth  space,  simply  enlarging  it,  inward  toward  the  edge 
of  the  sternum  and  outward  toward  the  mammary  line,  sufficiently  to 
expose  the  pericardial  sac.  As  the  incision  is  carried  inward  toward 
the  sternum  the  internal  mammary  vessels  are  recognized  about  one- 
half  inch  distant  from  the  edge  of  the  sternum.  The  vessels  are 
ligated  double  and  divided  and  the  incision  then  continued  inward 
right  up  to  the  edge  of  the  sternum.  The  incision  is  prolonged  in  an 
outward  direction  toward  or  even  beyond  the  mammary  line.  As  the 
incision  is  carried  outward  toward  the  mammary  line  the  edge  of  the 
pleural  sac  is  incised  and  the  pleural  cavity  freely  opened.  The  edges 
of  the  incision  (costal  cartilages)  are  strongly  retracted  and  the  peri- 
cardial sac  thus  exposed.  If  more  room  is  required  the  ends  of  the 
cartilages  of  the  ribs  above  and  below,  as  may  be  necessary,  are  cut 
away  at  their  sternal  attachments.  The  wound  is  held  wide  open  by 
forcibly  retracting  the  edges.  If  necessary  an  osteoplastic  resection  of 
the  sternum  may  be  added,  turning  the  osteoplastic  sternal  flap  over 
toward  the  right  side.  The  pleural  cavity  is  drained  either  through 
the  outer  end  of  the  incision  or  else  a  small  stab  incision  may  be  made 
in  the^ighth  or  ninth  intercostal  space,  near  the  axillary  line,  and  the 
drain  introduced  into  the  pleural  cavity  through  this  opening. 

OPERATIONS  UPON  THE  PLEURA. 

Thoracentesis. — Puncture  through  the  chest  wall  into  the  pleural 
cavity. 

This  operation  may  be  performed  to  show  the  presence  and  to 
determine  the  nature  of  fluid  in  the  pleural  cavity  or  to  evacuate  such 


316  THORAX. 

fluid.  If  for  diagnosis  only,  an  ordinary  hypodermic  S5a'inge  may  be 
used.  If  necessary  to  evacuate  a  considerable  quantity  of  fluid,  a  rather 
good-sized  aspirating  needle  attached  to  a  Dieulafoy  syringe  may  be 
employed.  The  patient  should  be  semirecumbent  or  lying  down.  The 
puncture  should  be  made  at  the  point  where  the  physical  signs  locate 
the  fluid.  To  aneesthetize  the  skin  a  spray  of  ethyl  chloride  may  be 
used.  Before  the  needle  is  introduced,  the  skin  is  drawn  upward  or 
downward  so  that  the  track  of  the  needle  through  the  muscles  may  not 
be  upon  the  same  level  as  the  puncture  in  the  skin.  The  needle  is 
thrust  into  the  chest  between  the  two  ribs,  nearer  the  lower  than  the 
upper  one. 

If  -the  operator  may  choose  the  point  at  which  the  needle  is  to  be 
introduced,  either  the  eighth  space,  just  below  the  angle  of  the  scapu- 
lar, or  the  sixth  space,in  the  middle  of  the  axilla,  just  in  front  of  the 
border  of  the  latissimus  dorsi,  is  usually  selected. 

The  fluid  should  be  evacuated  slowly,  and,  if  the  quantity  is  great, 
care  should  be  taken  not  to  remove  too  much.  One  should  stop  if  per- 
sistent cough  occurs  or  if  the  pulse  changes.  At  times,  the  needle 
becomes  plugged  with  pieces  of  fibrin,  which  may  be  dislodged  by 
introducing  a  stylet  or  by  pumping  some  of  the  fluid  back  into  the 
pleural  cavity.  After  the  fluid  has  been  withdrawn  the  needle  is 
removed  and  the  small  wound  in  the  skin  covered  with  collodion,  etc. 

It  is  necessary  to  remember  that  the  lower  limits  of  the  pleural 
cavity  fall  short  of  the  free  border  of  the  ribs,  and,  further,  that  if  the 
needle  is  inserted  straight  inward  for  a  considerable  distance  it  may 
pass  through  the  pleura  and  diaphragm  into  the  abdominal  cavity. 
If  we  find  pus  in  the  pleural  cavity,  in  the  adult,  it  is  necessary 
to  establish  drainage,  resecting  part  of  a  rib.  In  the  child  it  often 
suflices  to  simply  evacuate  the  pus  with  the  aspirator  without  providing 
drainage. 

Thoracotomy. — This  means  cutting  through  the  wall  of  the  chest, 
usually  with  the  resection  of  part  of  a  rib,  for  the  purpose  of  estab- 
lishing drainage.  • 

The  patient  lies  upon  his  well  side,  and  should  be  anaesthetized. 
The  seventh  rib,  that  portion  of  it  which  lies  anterior  to  the  latis- 
simus dorsi,  is  usually  resected,  as  this  is  not  covered  by  muscle  and 
is  sufficiently  low  for  proper  drainage. 

Immediately  before  proceeding  with  the  operation  the  exploring 
needle  should  be  inserted  in  order  to  ascertain  positively  the  location 
of  the  pus,  and  there,  where  the  pus  is  located,  should  the  opening 


OPERATIONS  UPON  THE  PLEURA.  317 

into  the  pleural  cavity  be  made.     As  already  mentioned,  if  we  have 
tlie  choice,  the  seventh  rib  is  the  one  selected  for  resection. 

The  incision,  usually  about  two  inches  long,  corresponds  to  the 
course  and  direction  of  the  rib  to  be  excised;  it  is  carried  down 
through  the  soft  parts,  including  the  periosteum,  upon  the  surface 
oJ:  the  rib.  With  the  elevator  the  periosteum  and  all  the  soft  parts 
are  peeled  off  the  bone,  which  is  thus  laid  bare.  Care  must  be  ex- 
ercised, in  working  around  the  upper  and  lower  borders  of  the  rib 
for  the  purpose  of  denuding  its  internal  surface,  not  to  perforate  the 
pleura  nor  wound  the  vessels  that  are  lodged  in  the  groove  along  the 
lower  border  of  the  rib.  When  the  length  of  bone  that  is  to  be  excised 
lias  been  denuded  of  its  periosteum  it  is  cut  through  at  either  end 
Math  the  sharp  bone-forceps.  The  opening  into  the  chest  cavity  is 
made  by  incising  the  pleura  with  the  Icnife.  The  opening  which  is 
thus  made  may  be  enlarged  by  introducing  an  artery  forceps,  the 
blades  of  which  are  spread  apart  as  they  are  withdrawn  so  as  to  make 
a  hole  large  enough  to  permit  exploration  of  the  interior  of  the  chest 
with  the  finger  and  the  introduction  of  one  or  two  good-sized  tubes. 

If  it  is  discovered,  with  the  finger  in  the  chest,  that  the  opening 
is  a  considerable  distance  above  the  bottom  of  the  pus  cavity,  it  may 
be  desirable,  in  order  to  facilitate  the  drainage,  to  make  a  second 
counter-opening  at  a  lower  level :  through  the  eighth  space,  for  in- 
stance, or  even  lower,  depending  upon  the  part  of  the  chest  which  is 
involved  (see  limits  of  lower  edge  of  pleura).  The  drainage  tube 
sliould  be  secured  to  the  edge  of  the  incision  in  the  skin  with  a  silk 
stitch  in  order  to  prevent  its  becoming  dislodged.  If  the  skin  wound 
is  unnecessarily  large,  it  may  be  partially  closed  with  one  or  two  silk 
sutures.  The  administration  of  20  or  30  minims  of  aromatic  spirits 
of  ammonia  hypodermically,  immediately  before  the  opening  is  made 
into  the  pleural  cavity,  will  often  ward  off  the  condition  of  collapse 
which  sometimes  occurs  at  this  time.  If  a  general  angesthetic  is  used, 
it  is  withdrawn  before  making  the  opening  in  the  pleura. 

In  recent  cases  of  empyema  where  the  adhesions  are  not  yet  very 
firm  the  lung  expands  after  the  pus  has  been  evacuated.  In  this  way 
the  cavity  is  obliterated  and  a  cure  of  the  condition  favored. 

Thoracotomy,  Xloyd. — In  cases  of  empyema  of  longer  duration 
and  in  cases  that  have  already  been  operated  and  failed  to  heal  the 
lung  will  be  found  contracted  and  adherent  either  in  the  upper  part 
of  the  pleural  cavity  or  else  drawn  toward  the  middle  line  and  ad- 
herent to  the  diaphragm.    In  these  cases,  owing  to  the  density  of  the 


318  THORAX. 

adhesions,  the  lung  is  unable  to  expand  and  fill  out  the  pleural  cavity, 
and  it  will  be  impossible  under  these  circumstances  to  achieve  a  cure. 

According  to  the  plan  of  Lloyd  on?  or  two  ribs  are  resected  to 
give  sufficient  room  and  the  fingers  or  hand  introduced  into  the  thorax 
and  the  adhesions  that  bind  the  lung  to  the  chest  wall,  diaphragm, 
etc.,  are  broken  up.  The  fingers  are  inserted  between  the  lung  and 
the  chest  wall  and  swept  around  in  all  directions  between  the  lung 
and  the  chest  wall  and  where  the  lung  is  adherent  to  the  diaphragm, 
betW'een  the  lung  and  the  diaphragm.  The  angesthetic  is  discontinued 
as  soon  as  the  chest  has  been  opened  so  that,  on  account  of  the  irrita- 
tion of  the  pleura  caused  by  the  manipulation  of  the  fingers  and  tear- 
ing of  adhesions  the  patient  coughs  violently  and  thus  assists  materially 
in  expanding  the  lung.  As  the  separation  of  the  adhesions  progresses 
the  lung  will  be  seen  to  expand  more  and  more  until  it  compeltely 
fills  the  pleural  space  and  in  this  way  obliterates  the  cavity  which 
served  as  a  reservoir  for  the  pus. 

The  opening  in  the  chest  wall  is  closed  with  silkworm-gut  sutures 
except  for  the  small  space  through  which  the  short  drainage  tube 
emerges. 

Thoracectomy,  Resection  of  the  Chest  Wall  (Estlaender). — This 
operation  is  practiced  in  old  chronic  cases  of  empyema — in  cases  where 
the  lung  cannot  expand  to  fill  out  and  obliterate  the  pleural  (pus) 
cavity.  The  operation  consists  in  resection  of  several  ribs  to  permit 
the  chest  wall  to  fall  in  upon  the  contracted  lung. 

An  oval  or  U-shaped  flap,  consisting  of  the  skin  and  subcutaneous 
fat,  with  its  base  behind,  at  the  axillary  line,  is  raised  from  the  side 
of  the  chest,  exposing  three  or  four  ribs ;  or  a  vertical  incision,  six 
inches  long,  may  be  made  in  the  axillary  line  over  the  fifth,  sixth, 
seventh,  and  eighth  ribs,  with  two  additional  incisions  along  the  course 
of  the  ribs,  the  middle  of  each  of  these  accessory  incisions  correspond- 
ing to  the  upper  and  lower  ends  of  the  vertical  incision.  The  two 
fiaps  which  are  thus  marked  out  are  reflected,  one  backward  and  the 
other  fonvard,  exposing  four  to  six  inches  of  three  or  four  ribs. 

Each  rib  is  denuded  of  its  periosteum  all  around,  as  described 
in  the  preceding  operation,  and  resected  with  the  bone  pliers.  A  long 
incision  is  then  made  in  the  pleura  and  the  thickened  pleura  excised. 
The  bleeding  is  controlled  by  clamps  and  ligatures.  The  cavity  of 
the  pleura  may  be  curetted  if  thought  necessary.  The  edges  of  the 
skin  flap  are  brought  together  with  several  silk  sutures  and  the  pleural 
cavity  packed. 


OPERATIONS  UPON  THE  PLEURA.  319 

Pleurectomy  (Fowler). — Detachment  and  excision  of  the  thick- 
ened, diseased  pleura,  visceral  and  parietal,  entire  or  in  part,  in  old, 
intractable  cases  of  empyema. 

An  incision  is  made  along  the  course  of  the  ribs  corresponding 
to  the  site  of  the  fistula,  which  is  always  present  (since  this  operation 
is  usually  practiced  in  cases  which  have  already  been  operated  upon 
unsuccessfully),  and  the  location  of  the  disease;  to  either  end  of  this 
incision  there  may  be  added  accessory  incisions,  an  anterior  and  a 
posterior.  The  flaps  that  are  thus  marked  out,  including  all  the  soft 
parts,  are  raised  so  as  to  expose  two  or  three  ribs  for  four  or  five 
inches  of  their  length.  Instead  of  the  incision  as  described  above  an 
elliptical  or  the  double  flap  incision,  as  described  in  the  Estlaender 
operation,  may  be  employed. 

The  periosteum  is  stripped  off  two  or  three  ribs  with  the  ele- 
vator, and  then  from  three  to  five  inches  of  the  two  or  three  ribs 
that  have  been  thus  denuded  are  resected  with  the  bone  forceps. 
All  bleeding  points  are  secured  with  artery  clamps  and  ligated. 
Cutting  from  the  fistula,  the  parietal  (costal)  pleura,  which  is  now 
exposed,  is  opened  up  with  a  free  incision,  and  entrance  thus  gained 
into  the  suppurating  pleural  cavity.  The  pleura  which  invests  the 
lung  (visceral)  is  incised,  and  by  blunt  dissection  with  the  finger  or 
with  the  blunt-pointed  scissors  this  is  peeled  off  the  lung;  here  and 
there  it  will  be  necessary  to  cut  a  band  with  the  scissors.  In  many 
cases  the  pleura  may  be  separated  from  the  lung  with  comparative 
ease,  and  this  should  be  done  with  care,  so  as  not  to  tear  into  the 
lung  tissue  proper. 

As  the  decortication  of  the  lung  progi-esses  there  may  be  con- 
siderable oozing  from  the  denuded  lung  surface,  but  this  may  be 
controlled  by  compression  with  gauze  pads,  which  are  applied  to  the 
bleeding  surface  following  up  the  fingers  of  the  operator  or  the  blunt 
scissors,  according  as  the  pleura  is  detached. 

After  the  pleura  has  been  peeled  off  the  lung  the  parietal  pleura 
is  stripped  off  the  chest  wall  and  then  off  the  diaphragm.  In  sepa- 
rating the  pleura  from  the  contiguous  portion  of  the  pericardial  sac 
care  must  be  exercised  to  avoid  any  undue  pulling  or  tearing.  As 
a  rule,  the  pleura  is  fairly  easily  separated  and  removed. 

At  times  it  will  be  found  more  convenient  to  commence  the  de- 
tachment of  the  pleura  by  stripping  it  away  from  the  chest  wall ;  it 
is  then  peeled  off  the  diaphragm,  and  finally  from  the  surface  of  the 
luncr. 


330  THORAX. 

.  Occasionally  the  conditions  that  exist  preclude  the  possibility 
■of  excising  all  of  the  diseased  pleura,  and  under  these  circumstances 
the  operator  must  content  himself  with  the  excision  of  the  visceral 
or  parietal  (costal  and  diaphragmatic)  pleura  in  part,  or  else  simply 
incise  the  visceral  pleura  and  strip  it  away  from  the  surface  of  the 
lung  without  removing  it. 

After  the  pleura  has  heen  removed,  either  entire  or  in  part,  the 
cavity  in  the  chest  is  loosely  tamponed  with  gauze  and  the  edges  of 
ihe  skin  approximated  with  silkworm-gut  sutures,  excej)t  for  a  part 
of  its  extent,  where  the  tampon  emerges. 

As  a  rule,  as  the  detaclnnent  of  the  pleura  from  the  lung  pro- 
gresses, the  lung  will  be  seen  gradually  to  expand  more  and  more. 

This  operation  has  the  advantage  of  removing  the  pathological 
suppurating  membrane,  and  besides  eliminates  an  obstacle  to  the 
•expansion  of  the  lung.  The  operation  is  not  advisable  in  cases  of 
diagnosable  pulmonary  tuberculosis.  The  discovery,  during  the 
course  of  the  operation,  of  tuberculous  deposits  in  the  lung  would 
warrant  the  surgeon  in  discontinuing  the  operation. 


PART  V. 

THE    ABDOMEN    AND    BACK. 


THE  ABDOMEN. 

The  abdomen  corresponds  to  the  lower  part  of  the  trunk,  and 
consists  of  a  ca\T[ty  with  elastic  mnscular  walls. 

Within  the  cavity  are  contained  the  chief  part  of  the  alimentary 
canal  and  the  organs  of  digestion  and  the  kidneys,  etc.  These  organs 
are  all  more  or  less  movable,  and  are  provided  with  a  more  or  less 
complete  investment  of  peritoneum. 

Externally  the  abdomen  is  limited  above  by  the  free  border  of 
the  costal  cartilages  and  below  by  the  crest  of  the  iliac  bone  of 
either  side  and  Poupart^s  ligaments.  The  walls  consist  almost  en- 
tirely of  soft  parts,  and  may  be  conveniently  considered  as  the  poste- 
rior and  the  antero-lateral.  The  capacity  of  the  abdominal  cavity  is 
greater  than  is  indicated  by  its  external  limitations. 

The  roof  of  the  abdominal  cavity  is  formed  by  the  diaphragm; 
helow,  the  abdominal  cavity  includes,  on  either  side,  the  iliac  fossa 
and  communicates  through  a  wide,  heart-shaped  opening  with  the 
cavity  of  the  true  pelvis.  The  margin  of  the  inlet  into  the  pelvic 
cavity  is  called  the  pelvic  brim. 

The  interior  of  the  cavity  of  the  abdomen  is  lined  by  the  parietal 
layer  of  the  peritoneum,  and  is  entirely  shut  off  from  communica- 
tion with  the  exterior  of  the  body  except  in  the  female,  where  a 
communication  exists  through  the  vagina,  uterus,  and  Fallopian  tubes, 
and  this  is  frequently  the  channel  through  which  infection  is  carried 
to  the  peritoneum  from  without. 

The  Diaphragm,  which  forms  the  roof  of  the  abdominal  cavity, 
is  a  musculo-aponeurotic  structure  that  separates  the  cavity  of  the 
chest  from  that  of  tlie  abdomen.  It  is  dome-shaped,  bulging  into 
the  cavity  of  the  thorax  and  presenting  its  lower  concave  surface  to 
the  abdominal  cavity.  It  arises  by  muscular  fibers,  which  vary  in 
length,  from  the  inner  surface  of  the  ensiform  process  of  the  ster- 
num and  from  the  inner  surface  of  the  cartilages  of  the  lower  ribs. 
Behind,  it  arises  from  the  ligamentum  arcuatum  externum  and  liga- 
mentiun  arcuatum  internum  and  by  its  two  crura  from  the  anterior 

21  (321) 


322  ABDOMEN  AND  BACK. 

surface  of  the  bodies  of  the  three  upper  lumbar  vertebrae.  From 
these  points  of  origin  the  muscular  fibers  converge  and  are  continued 
into  a  three-leafed  aponeurotic  structure :  the  central  tendon  of  the 
diaphragm.  Biehind  the  diaphragm  there  is  an  opening,  the  aortic, 
through  which  the  aorta  passes  from  the  thoracic  into  the  abdom- 
inal cavity;  the  posterior  boundary  of  this  opening  corresponds 
to  the  body  of  the  twelfth  dorsal  vertebra.  In  the  back  part  of  the 
diaphragm,  a  little  to  the  left  of  the  middle  line,  there  is  an  open- 
ing which  is  surrounded  by  muscular  fibers  and  through  which 
the  oesophagus  passes  to  the  cardiac  end  of  the  stomach.  To  the 
right  of  the  middle  line,  toward  the  front,  at  the  junction  of  the 
right  and  middle  segments  of  the  central  tendon,  there  is  an  opening 
for  the  passage  of  the  inferior  vena  cava;  the  edges  of  this  opening 
are  formed  of  aponeurotic  fibers.  The  heart,  wrapped  in  its  peri- 
cardial sac,  rests  upon  the  upper  surface  of  the  central  tendon  of  the 
diaphragm. 

In  front,  close  to  the  sternum,  on  either  side  of  the  bundle  of 
fibers  which  arises  from  the  ensiform  process,  there  is  a  space  where 
the  muscular  fibers  of  the  diaphragm  are  absent;  so  that,  in  this 
situation,  an  opening  exists  through  which  the  contents  of  one  cavity 
may  be  forced  into  the  other,  giving  rise  to  a  so-called  diaphragmatic 
hernia. 

On  the  right  side,  owing  to  the  presence  of  the  liver,  the  dia- 
phragm reaches  higher  into  the  chest  than  on  the  left.  The  thoracic 
surface  of  the  diaphragm  is  covered  by  a  thin  fascia,  the  fascia  endo- 
thoracica;  the  abdominal  surface  is  likemse  covered  by  a  fascia  which 
is  very  thin,  the  fascia  transversalis. 

The  Posterior  Wall  of  the  Abdomen,  the  lumbar  region  of  the 
back,  corresponds  to  the  five  lumbar  vertebrae  and  to  the  several 
muscles  which  fill  in  the  space  between  the  last  rib  and  the  crest 
of  the  ilium  on  either  side  of  the  spinal  column.  Externally  we  find 
the  skin  and  beneath  this  the  subcutaneous  fatty  layer.  Between 
the  muscles  of  the  lumbar  region  there  are  interposed  strong  layers  of 
fascia  which  serve  to  strengthen  this  region  very  much.  The  in- 
ternal or  abdominal  aspect  of  the  posterior  wall  of  the  abdomen  is 
lined  by  that  part  of  the  transversalis  fascia  which  covers  the  psoas 
and  quadratus  lumbonmi  muscles. 

The  kidney,  inclosed  within  its  fatty  capsule,  is  located  in  the 
lumbar  region  between  the  transversalis  fascia — i.e.,  the  anterior 
layer  of  the  lumbar  fascia — and  the  parietal  peritoneum,   its  ante- 


ABDOMEN.  323 

rior  surface  only  being  covered  by  the  peritoneum ;  so  that  the  organ 
is  thus  exchided  from  tlie  peritoneal  cavity. 

The  Antero-Lateral  Wall  of  the  Abdomen  is  made  up  of  several 
layers  of  soft  parts.  It  consists  of  the  skin  with  its  underlying  fatty 
layer;  several  broad,  flat  muscles,  the  oblique,  the  transversalis,  and 
the  recti;  and  the  aponeuroses  which  correspond  to  these  muscles. 
The  fascia  transversalis  is  found  beneath  the  muscles,  and  beneath 
the  fascia  transversalis  the  subperitoneal  fat  is  encountered,  and, 
finally,  deepest,  most  internal  of  all,  is  the  parietal  peritoneum. 

In  the  female  the  abdomen  is  more  rounded  and  contains  a  con- 
siderable pad  of  fat;  in  the  male,  especially  in  athletes,  the  fatty 
layer  is  less  marked  or  almost  entirely  absent;  so  that  the  markings 
of  the  muscles  show  througli  the  skin  and  give  the  characteristic  ap- 
pearance to  the  abdomen. 

In  the  middle  line,  al)out  midway  between  the  ensiform  process 
and  the  symphysis  pubis,  there  is  a  well-marked  depression,  the  navel ; 
this  is  an  important  landmark,  although  its  position  may  vary  some- 
what in  different  individuals,  and  marks  the  place  where  the  foetal 
umbilical  vessels  and  fcetal  channels  enter  and  pass  out  of  the  abdo- 
men. Above,  in  the  middle  line,  is  the  ensiform  process  of  the  ster- 
num, and  passing  downward  from  this  there  is  a  furrow  which  corre- 
sponds to  the  space  between  the  rectus  muscles,  but  which  does'  not 
reach  downward  as  far  as  the  symphysis.  On  either  side  of  the 
middle  line,  corresponding  to  the  outer  border  of  the  rectus,  is  the 
location  of  the  linea  semilunaris.  Below,  on  either  side,  the  anterior 
superior  iliac  spines — important  surgical  landmarks — ^may  be  seen, 
and  upon  the  pubic  bones,  on  either  side  of  and  close  to  the  sym- 
physis, the  spinous  processes  of  the  pubes  may  be  felt. 

Corresponding  to  Poupart's  ligament,  which  reaches  from  the 
anterior  superior  spine  to  the  spine  of  the  pubes,  there  is  a  linear 
crease  in  the  skin  which  separates  the  abdomen  from  the  front  of 
the  thigh. 

The  whole  abdomen  is  covered  by  the  skin,  underneath  which 
is  the  subcutaneous  fat;  the  al)domen  is  a  favorite  site  for  the  accu- 
mulation of  fat  in  the  obese,  and  this  layer  varies  much  in  thickness 
in  difi'erent  individuals;  it  is  continuous  with  the  corresponding 
fatty  layer  upon  the  breast  and  below  with  the  fat  of  the  thighs. 
At  the  navel  the  fat  is  absent,  the  skin  being  depressed  and  fixed 
to  the  aponeurosis  beneath,  so  that  the  depth  of  the  navel  corre- 
sponds to  the  thickness  of  the  abdominal  pad  of  fat.     The  subcuta- 


324  ABDOMEN  AND  BACK. 

neoiTS  fatt}^  laj'er  may  be  readily  separated  from  the  underlying  mus- 
cle and  aponeurosis,  leaving  these  structures  covered  by  a  thin,  loose, 
cellular  fascia,  the  so-called  deep  layer  of  the  superficial  fascia,  but 
which  is  really  a  part  of  the  subcutaneous  connective-tissue  layer. 
This  fascia  is  more  intimately  attached  to  the  linea  alba  and  Pou- 
part's  ligament  and  to  the  pillars  of  the  external  inguinal  ring  than 
elsewhere.  From  the  pillars  of  the  ring  it  is  prolonged  downward 
around  the  spermatic  cord  and  into  the  scrotum,  where  it  is  con- 
tinuous with  the  dartos. 

The  Superficial  Vessels  of  the  Abdominal  Wall. — In  the  subcu- 
taneous fatty  layer  the  superficial  arteries  and  veins  ramify. 

Above,  branches  of  the  superior  epigastric,  which  perforate  the 
rectus  and  the  anterior  layer  of  its  sheath,  are  distributed  to  the 
integument  and  subcutaneous  tissue.  Below,  the  superficial  epi- 
gastric artery,  which  is  derived  from  the  femoral,  curves  obliquely 
upward  across  Poupart's  ligament  toward  the  umbilicus  and  supplies 
the  skin  and  fat  in  this  region.  Upon  the  sides  of  the  abdomen 
branches  that  are  given  off  from  the  lumbar  arteries  pierce  the  mus- 
cles and  ramify  in  the  subcutaneous  tissue.  These  vessels  are  all 
accompanied  by  their  corresponding  veins.  Underneath  the  skin 
of  the  abdomen  are  seen  many  large  veins  which  communicate  with 
those  within  the  abdomen,  and  therefore  when  the  blood-current  is 
obstructed  in  the  portal  vein  or  the  vena  cava  these  superficial  ab- 
dominal veins  become  swollen  and  prominent  and  are  readily  recog- 
nized beneath  the  skin. 

After  the  skin  and  subcutaneous  fatty  layer,  including  the  thin, 
deep  layer  of  the  superficial  fascia,  have  been  removed  from  the 
front  and  sides  of  the  abdomen,  the  broad,  strong  aponeurosis  of  the 
external  oblique  upon  the  front  of  the  abdomen  and  the  fleshy  por- 
tion of  this  same  muscle  upon  the  side  of  the  abdomen  are  exposed. 

The  Muscles  of  the  Antero-Lateral  Wall.  The  Exteknal 
Oblique  is  a  broad,  flat  muscle,  the  most  superficial  of  the  abdom- 
inal muscles,  and  occupies  the  side  of  the  abdomen.  The  muscle 
arises  by  fleshy  slips  from  the  external  surface  of  the  eight  lower 
ribs,  interdigitating  with  the  processes  of  origin  of  the  pectoral  is 
major  and  the  latissimus  dorsi.  The  fibers  of  this  muscle  have  a 
general  oblique  direction,  downward,  forward,  and  inward,  terminat- 
ing in  the  broad,  strong  aponeurosis  which  occupies  the  front  of  the 
abdomen.  Those  fibers  which  arise  from  the  lowest  ribs  pass  almost 
directly  downward  and  are  attached  to  the  anterior  half  of  the  outer 


A13D0MEN.  325 

lip  of  the  crest  of  the  ilium.  The  posterior  free  border  of  the  ex- 
ternal oblique  muscle  forms  the  anterior  boi-der  of  the  triangle  of 
Pettit.  The  posterior  border  of  this  ti'ianglc  is  foiincd  by  the  outer 
free  edge  of  the  latissimus  dorsi,  its  base  by  the  crest  of  the  iliac 
bone,  its  floor  by  the  internal  oblique  muscle. 

The  aponeurosis  of  the  external  oblique  is  a  broad,  strong,  pearly 
white,  o-listenino-  fibrous  structure  which  occupies  the  front  of  the 
abdomen  and  is  exposed  after  the  integument  and  underlying  fatty 
layer  (superficial  fascia)  have  been  removed.  The  fibers  of  the  apo- 
neurosis are,  for  the  most  part,  directed  downward  and  inward,  cov- 
ering in  the  recti  and  joining  in  the  middle  line,  between  these 
muscles,  to  form  the  linea  alba. 

The  linea  alba  is  a  strong,  fibrous  band  which  reaches  from  the 
ensiform  cartilage  above  to  the  symphysis  pubis  below;  it  marks  the 
union  of  the  aponeuroses  of  either  side  and  separates  the  recti  from 
each  other.  The  linea  alba  is  interrupted  by  the  navel.  Above  the 
navel  the  linea  alba  is  broad :  in  the  epigastric  region  it  is  _1  to  2 
cm.  wide,  and  below,  toward  the  navel,  becomes  still  broader.  Below 
the  navel,  however,  it  is  not  so  broad,  owing  to  the  closer  approxi- 
mation of  the  edges  of  the  recti.  Above,  where  it  is  broad,  it  is  thin 
from  before  backward,  and  below,  where  it  is  narrow,  it  is  thick 
from  before  backward.  Below,  at  its  attachment  to  the  symphysis 
pubis,  it  spreads  out  and  is  known  as  the  adminiculum  linese  albae. 

Those  fibers  of  the  aponeurosis  of  the  external  oblique,  that 
pass  from  the  anterior  superior  spine  of  the  ilium  downward  and 
inward  to  the  spine  of  the  pubes,  form  Poupart's  ligament ;  where 
this  ligament  is  attached  to  the  pubic  spine,  the  aponeurosis  of  the 
external  oblique  splits  and  leaves  a  triangular  opening  which  is  called 
the  external  inguinal  ring,  and  through  this  the  spermatic  cord  in 
the  male,  and  the  round  ligament  in  the  female,  emerge.  BeloAV  Pou- 
part's,  the  aponeurosis  is  continuous  with  the  fascia  lata  of  the  front 
of  the  thigh. 

Along  the  outer  edge  of  the  rectus,  at  the  linea  semilunaris,  the 
aponeurosis  of  the  external  oblique  is  blended  with  the  aponeuroses 
of  the  underlying  muscles;  from  the  linea  semilunaris  the  aponeu- 
rosis is  continued  inward,  forming  the  anterior  layer  of  the  sheath 
of  the  rectus,  and  in  the  middle  line  joins  with  that  of  the  opposite 
side  to  form  the  linea  alba. 

The  Internal  Oblique  Muscle  lies  beneath  the  external 
oblique  upon  the  side  of  the  abdomen,   a   thin,   loose,  cellular  con- 


326  ABDOMEN  AKD  BACK. 

nective  tissue  being  interposed  between  them.  The  fibers  of  this 
muscle  have  a  direction  the  opposite  to  those  of  the  external  oblique. 

This  muscle  arises  below  from  the  anterior  two-thirds  of  the 
middle  lip  of  the  crest  of  the  ilium  and  from  the  outer  half  of 
Poupart's  ligament.  From  this  origin  the  fibers  pass  in  a  general 
direction  upward  and  forward^  some  being  attached  to  the  lower 
border  of  the  cartilages  of  the  four  lower  ribs,  the  others  terminat- 
ing in  the  anterior  aponeurosis,  at  the  outer  border  of  the  rectus, 
the  linea  semilunaris.  The  lowermost  fibers,  which  arise  from  Pou- 
part's ligament,  pass  inward  and  then,  curving  downward,  join  with 
a  similar  process  from  the  transversalis  to  form  the  conjoined  tendon, 
which  is  attached  to  the  crest  of  the  os  pubis. 

The  Teaxsversalis  is  the  deepest  of  the  three  broad  abdom- 
inal muscles.  It  occupies  the  side  of  the  abdomen  lying  next  beneath 
the  internal  oblique,  a  thin,  loose,  cellular  connective  tissue  inter- 
vening between  them.  Its  fibers  have  a  transverse  direction.  This 
muscle  arises  behind,  through  the  lumbar  fascia,  from  the  transverse 
processes  and  spines  of  the  lumbar  vertebrae;  above,  from  the  inner 
surface  of  the  six  lower  ribs;  below,  from  the  crest  of  the  ilium  and 
the  outer  one-third  of  Poupart's  ligament.  The  fibers  pass  forward 
and  inward,  and,  at  the  outer  border  of  the  rectus,  termiDate  in  the 
anterior  aponeurosis.  Those  fibers  of  the  transversalis  which  arise 
from  Poupart's  ligament  pass  inward,  and  curving  downward  join 
with  a  similar  process  from  the  internal  oblique  to  form  the  con- 
joined tendon,  which  is  attached  to  the  crest  of  the  pubes  behind 
the  external  inguinal  ring.  Beneath  the  transversalis  muscle,  the 
transversalis  fascia,  which  lines  the  whole  inner  surface  of  the  ab- 
domen, is  found. 

The  Pectus  is  a  long,  flat  muscle  occupying  the  front  of  the 
abdomen,  one  on  either  side  of  the  middle  line,  the  linea  alba  being 
interposed  between  them. 

Above,  the  rectus  muscles  are  broad  and  attached  to  the  carti- 
lages of  the  fifth,  sixth,  seventh,  and  eighth  ribs  and  to  the  sides  of 
the  ensiform  cartilage.  Below,  they  become  narrow  and  are  attached 
to  the  symphysis  and  crest  of  the  pubes.  The  recti  are  marked  by 
several  transverse  fibrous  intersections,  which  are  united  to  the  ante- 
rior layer  of  the  sheath  of  this  muscle,  but  not  to  the  posterior ;  they 
are  usually  three  in  number,  two  above  the  umbilicus  and  one  below. 

The  Apon'euroses  of  the  external  and  internal  oblique  and 
transversalis  are  blended  with  each  other  along  the  outer  border  of 


SMALL 
fNT£ST' 


Fig.  153. — Transverse  Section  of  the  Abdomen  Above  ttie  Semilunar  Fold 
of  Douglas.  -4.-1,  anterior  layer  of  the  split  aponeurosis  of  the  oblique  and 
transversalis  muscles — anterior  layer  of  sheath  of  the  rectus;  EO,  externa! 
oblique  muscle;  JO,  internal  oblique  muscle;  A',  kidney;  LD,  latissimus  dorsi 
muscle;  .1/,  mesentery  (suspends  small  intestine  to  vertebral  column);  PA. 
posterior  layer  of  split  aponeurosis  of  the  oblique  and  transverse  muscles — 
posterior  layer  of  sheath  of  rectus;  T.  T.  transversalis  fascia;  TR,  transversalis 
muscle;  red  line  represents  the  peritoneum. 


Fig.  154. — Transverse  Section  of  the  Abdomen  Below  the  Semilunar  Fold  of 
Douglas,  Showing  the  Entire  Aponeurosis  Passing  in  Front  of  the  Rectus 
Muscle.  A,  aponeurosis  of  the  abdominal  muscles  (oblique  and  transversalis  i 
passing  undivided  in  front  of  the  rectus. 


328  ABDOMEN  AND  BACK. 

the  rectus  muscle.  Here^  corresponding  to  the  linea  semilunaris, 
they  form  one  aponeurotic  layer.  At  the  outer  border  of  the  rectus 
the  conjoined  aponeurosis  splits  into  two  layers, — an  anterior  and 
a  posterior, — and  these  include  the  rectus  between  them,  one  pass- 
ing in  front  of  the  muscle  and  the  other  behind  it,  and  both  joining 
again  Avith  each  other,  between  the  recti,  in  the  middle  line,  to  form 
the  linea  alba.  This  disposition  of  the  aponeurosis  and  sheath  of 
the  rectus  is  very  simple  and  holds  for  the  upper  three-fourths  of 
the  muscle.  Corresponding  to  the  lower  fourth  of  the  rectus,  the 
whole  aponeurotic  layer,  without  splitting,  passes  in  front  of  the 
muscle;  so  that  this  lower  fourth  of  the  rectus,  upon  its  posterior 
aspect,  is  without  a  proper  sheath  and  is  covered  only  by  the  general 
fascia  transversalis.  Upon  the  posterior  aspect  of  the  rectus,  where 
the  posterior  layer  of  the  sheath  terminates,  it  presents  a  sharp, 
curved  edge :    the  semilunar  fold  of  Douglas. 

The  Fascia  Transversalis. — Lining  the  inner  surface  of  the 
transversalis  muscle  and  coatinued  over  the  whole  internal  surface 
of  the  abdomen  is  a  strong  fascia,  the  fascia  transversalis.  Above, 
this  fascia  is  thin  and  lines  the  abdominal  surface  of  the  diaphragm. 
In  front  and  upon  the  sides  it  lines  the  internal  aspect  of  the  mus- 
cles, etc.,  that  form  the  antero-lateral  wall  of  the  abdomen.  In  the 
inguinal  region  it  is  rather  thicker.  Behind,  upon  the  posterior  wall 
of  the  abdomen  the  fascia  covers  the  psoas  and  quadratus  lumborum 
muscles,  forming  in  this  situation  the  anterior  layer  of  the  lumbar 
fascia.  This  portion  of  the  fascia,  being  traced  downward,  is  seen 
to  invest  the  psoas  and  iliacus  muscles  and  is  attached  to  the  inner 
lip  of  the  crest  of  the  ilium  and  to  Poupart's  ligament  except  where 
the  femoral  vessels  escape,  under  the  ligament,  into  the  thigh.  As 
the  psoas  and  iliacus  muscles  pass  out  of  the  abdomen,  under  Pou- 
part's ligament,  into  the  thigh,  the  fascia  accompanies  and  invests 
them.  That  portion  of  the  fascia  which  covers  and  invests  the  psoas 
and  iliacus  muscles,  both  within  the  abdomen  and  also  in  the  thigh, 
under  Poupart's  ligament,  is  known  as  the  fascia  iliaca.  The  fascia 
also  dips  down  into  the  true  pelvis,  lining  its  internal  wall,  muscles, 
etc.,  providing  more  or  less  complete  sheaths  to  the  pelvic  viscera  and 
is  here  known  as  the  pelvic  fascia.  All  these  fascise,  though  having 
different  names,  are  simply  parts  of  the  general  transversalis  fascia 
or  fascia  endoabdominalis. 

The  Parietal  Peritoneum. — ^The  whole  interior  of  the  abdominal 
cavity  is  lined  by  the  parietal  layer  of  the  peritoneum.     Between 


ABDOMEN.  339 

this  parietal  layer  of  the  peritoneum  and  the  transversalis  fascia 
there  is  a  layer  of  loose  connective  tissue  which  contains  a  variable 
quantity  of  fat.    This  is  the  subperitoneal  connective  tissue. 

Through  an  incision  in  the  anterior  abdominal  wall  placed  just 
to  the  left  of  the  middle  line,  we  may  study  the  round  ligament  of 
the  liver.  This  structure  is  the  remains  of  the  fcctal  umbilical  vein 
and  reaches  from  the  posterior  aspect  of  the  navel  upward  and  to 
the  right  as  far  as  the  under  surface  of  the  liver.  A  fold  of  the 
parietal  peritoneum,  which  is  reflected  from  the  anterior  abdominal 
wall   around  the  round  ligament,   is   called   the   falciform   ligament. 

Accompanying  the  round  ligament  of  the  liver  from  the  region 
of  the  umbilicus  are  several  veins;  one,  the  largest,  enters  the 
portal  system,  and  thus  establishes  a  communication  l)etween  the 
veins  of  the  wall  of  the  abdomen  and  the  portal  circulation. 

Eeaching  downward,  in  the  middle  line  from  the  umbilicus  to 
the  summit  of  the  bladder,  is  the  urachus.  This  is  a  musculo-fibrous 
cord, — the  remains  of  the  foetal  allantois, — and  may  be  found  more 
or  less  pervious  in  the  child  or  adult;  so  that  a  communication  may 
thus  exist  between  the  umbilicus  and  the  bladder.  As  the  parietal 
peritoneum  which  lines  the  posterior  surface  of  the  anterior  abdom- 
inal wall  passes  over  the  urachus,  it  is  raised  in  tlie  form  of  a 
distinct  longitudinal  fold:    the  plica  vesico-umbilicalis  media. 

The  Deep  Vessels  of  the  Abdominal  Wall. — Between  the  layers 
of  the  muscles  of  the  abdomen  the  deep  vessels  of  the  abdominal 
wall  ramify.  Above  are  found  the  terminal  l)ranches  of  the  internal 
mammary,  the  superior  epigastric,  and  the  musculo-phrenic.  The 
superior  epigastric  is  continued  from  the  thorax,  through  the  open- 
ing in  the  diaphragm,  between  its  costal  and  sternal  portions;  it 
pierces  the  posterior  layer  of  the  sheath  of  the  rectus,  supplies  this 
muscle  and  gives  off  branches  which  perforate  the  muscle  and  the 
anterior  la}er  of  its  sheath  to  supply  the  subcutaneous  tissue  and 
skin  of  the  abdomen.  It  anastomoses  with  branches  of  the  super- 
ficial epigastric  and  deep  (inferior)  epigastric. 

Below,  the  deep  epigastric  and  deep  circumflex  iliac,  which  are 
derived  from  the  external  iliac,  are  encountered ;  these  are  siven 
off  just  before  this  vessel  passes  under  Poupart's  ligament  to  become 
the  femoral. 

The  deep  epigastric  is  directed  upward  and  inward  toward 
the  umljilicus.  resting  upon  the  posterior  surface  of  the  rectus, 
between   the   transversalis  fascia   and   the   parietal   peritoneum,    and 


330  ABDOMEN  AND  BACK. 

enters  the  substance  of  this  muscle  below  the  semilunar  fold  of 
Douglas^  suppl}dng  it  and  anastomosing  with  the  end  branches  of 
the  superior  epigastric.  Some  branches  from  this  vessel  pierce  the 
anterior  layer  of  the  sheath  of  the  rectus  muscle  and  ramify  in  the 
fatty  layer  beneath  the  skin. 

The  deep  circum.flex  iliac  passes  upward  and  outward  beneath 
and  parallel  with  Poupart's  ligament  toward  the  anterior  superior 
iliac  spine;  it  then  runs  along  the  crest  of'  the  ilium  and  after 
piercing  the  transversalis  fascia  is  distributed  to  the  muscles  of  the 
abdomen. 

From  behind  come  the  abdominal  branches  of  the  lumbar  arteries : 
iTSually  four.  They  pass  forward  between  the  muscles  and  anastomose 
with  the  branches  of  the  musculo-phrenic^  superior  epigastric,  the 
deep  epigastric^,  and  the  deep  circumflex  iliac.  These  arteries  are  all 
accompanied  by  their  corresponding  veins. 

The  Regions  of  the  Abdomen. — The  surface  of  the  abdomen  may 
be  marked  off  into  areas  by  several  imaginary  lines  which  intersect 
each  other.  Two  of  these  are  transverse,  the  upper  passing  through 
the  tips  of  the  tenth  ribs,  the  lower  through  the  highest  points  of 
the  iliac  crests.  '  These  are  crossed  by  two  lines  which  pass  from 
the  tip  of  the  tenth  rib  of  either  side  downward  and  inward  to  the 
pubic  sjDine. 

Above  the  upper  transverse  line  is  the 
(a)   Eegio  epigastrica; 
between  the  two  transverse  lines  is  the 

(&)   Eegio  mesogastrica ; 

and  below  the  lower  transverse  line  is  the 

(c)   Eegio  h3^pogastrica. 

The  regio  epigastrica  is  subdivided  into  three  portions : — ^ 

1.  Eegio  epigastrica  proper. 

2.  Eegio  hypochondriaca  dextra. 

3.  Eegio  hj'pochondriaca  sinistra. 

The  regio  mesogastrica  is  subdivided  into  three  portions: — 

1.  Eegio  umbilicalis. 

2.  Eegio  abdominis  lateralis  dextra. 

3.  Eegio  abdominis  lateralis  sinistra. 

The  regio  hypogastrica  is  subdivided  into  three  portions : — 

1.  Eegio  pubica. 

2.  Eegio  inguinalis  dextra. 

3.  Eegio  inguinalis  sinistra. 


Fig  155  —The  Regions  of  the  Abdomen  as  Indicated  by  Two  Transverse 
Lines  drawn  through  the  Tips  of  the  Cartilages  of  the  Tenth  Ribs  and  the 
Anterior  Superior  Iliac  Spines  and  Two  Oblioue  Lines  drawn  from  the  Tips 
of  the  same  Cartilages  down  to  the  Pubic  Spines.  The  liver  and  gall-bladder 
are  indicated  in  orange,  stomach  and  duodenum  in  red  (dotted  lines  repre- 
sent that  part  of  the  duodenum  which  lies  behind  the  stomach).  The  pan- 
creas and  colon  are  indicated  in  blue,  the  kidneys  in  green. 


332  ABDOMEN  AND  BACK. 

THE  BACK. 

When  we  speak  of  the  back  we  mean  the  whole  posterior  part 
of  the  trunk.  The  back  may  be  divided  into  three  regions :  the 
dorsal,  the  lumbar,  and  the  sacral. 

It  is  better  to  consider  the  back  as  a  whole,  since  these  regions 
merge  directly  into  each  other  without  any  definite  dividing  line. 

Above  the  back  is  limited  by  the  vertebra  prominens  and  below 
by  the  tip  of  the  coccyx.  The  dorsal  portion  corresponds  to  the 
chest,  and  includes  the  dorsal  vertebrae  and  the  ribs,  the  scapulse 
and  the  muscles  of  this  region.  The  lumbar  portion  forms  the  poste- 
rior wall  of  the  abdominal  cavity,  and  includes  the  five  lumbar  ver- 
tebrae and  the  thick  mass  of  muscle  on  either  side  which  fills  in  the 
space  between  the  last  rib  and  crest  of  the  ilium. 

The  sacral  region  corresponds  to  the  posterior  wall  of  the  true 
pelvic  cavity  and  includes  the  sacrum  and  the  coccyx. 

In  the  middle  of  the  back  there  is  a  longitudinal  furrow  in 
which  the  spinous  processes  of  the  vertebrae,  from  the  seventh  cer- 
vical, vertebra  prominens,  above,  to  the  sacrum  below,  may  be  dis- 
tinctly felt ;  those  which  correspond  to  the  sacrum  are  less  prominent. 

To  either  side  of  this  inedian  furrow  there  is  a  prominent  mass 
formed  by  the  longitudinal  muscles  of  the  back.  These  masses  ex- 
tend from  the  sacrum  to  the  occiput,  and,  the  more  pronounced  they 
are,  the  deeper  is  the  median  groove. 

In  the  dorsal  region,  on  either  side,  are  the  scapulae — ^shoulder- 
blades.  These  bones  are  triangular  in  shape  and  are  located  between 
the  first  and  eighth  ribs  toward  the  outer  part  of  the  thorax.  The 
inner  or  vertebral  border  of  the  scapula  is  nearly  parallel  with  the 
spinous  processes  of  the  vertebrae  when  the  arm  hangs  by  the  side. 
This  bone  is  freely  movable  and  its  position  varies  according  to  the 
position  of  the  upper  extremity.  The  spine  of  the  scapula  is  felt 
beneath  the  skin  and  may  be  traced  outward  and  upward;  its  outer 
end,  which  is  prolonged  outward  and  flattened  from  above  down- 
ward, is  called  the  acromion  process  and  overhangs  the  shoulder- 
joint,  articulating  with  the  outer  end  of  the  clavicle.  The  lower 
extremity  of  the  scapula,  the  angle,  corresponds  to  the  eighth  rib, 
and  is  a  surgical  landmark  of  some  value. 

The  skin  and  subcutaneous  connective  tissue  of  the  back  is 
continuous  with  the  corresponding  layers  of  the  adjoining  parts  of 
the  trunk.  The  subcutaneous  tissue  is  rather  finii  and  fibrous  and 
contains  a  varying  amount  of  fatty  tissue.     The  deep  fascia  of  the 


BACK.  333 

back  is  a  strong,  dense,  fibrous  layer  which  covers  in  the  superficial 
muscles;  it  is  attached  in  the  middle  line  to  the  spinous  processes 
of  the  vertebrse  and  may  be  traced  upward,  upon  the  trapezius  mus- 
cle, as  far  as  the  occipital  bone,  to  which  it  is  attached.  In  the  dorsal 
region  it  is  attached  to  the  subcutaneous  surface  of  the  spine  of  the 
scapula.  Below  it  is  attached  to  the  crest  of  the  ilium  and  to  the 
sacrum. 

The  Muscles  of  the  Back  are  numerous  and  may  be  divided  into 
several  layers. 

First  Layer  of  Muscles.— Trapezius  and  latissimus  dorsi. 

The  Trapezius  is  a  broad,  flat  mnscle,  one  on  either  side;  to- 
gether they  are  lozenge-shaped  and  occupy  the  dorsal  and  cervical 
regions.  Each  muscle  arises  from  the  superior  curved  line  of  the 
occipital  bone,  from  the  ligamentum  nuchse,  which  corresponds  to 
the  spinous  processes  of  the  cervical  vertebrae,  and  from  the  spinous 
processes  of  all  the  dorsal  vertebrae.  From  this  extensive  origin  the 
mnscle  of  each  side  is  attached  as  follows :  Those  fibers  which  arise 
from  the  occipital  bone  pass  downward,  outward,  and  forward,  and 
are  attached  to  the  upper  surface  of  the  outer  one-third  of  the  clav- 
icle; those  from  the  dorsal  and  cervical  vertebrae  converge  and  are 
attached  to  the  whole  length  of  the  npper  border  of  the  spine  of 
the  scapula.  That  portion  of  the  muscle  which  corresponds  to  the 
lower  cervical  and  npper  dorsal  vertebrae  shows  an  aponeurotic  origin, 
which,  together  with  that  of  the  opposite  side,  is  oval  in  shape. 

The  Latissimus  Dorsi  is  broad,  triangle-shaped,  and  flat,  and 
occupies  the  lumbar  and  lower  dorsal  regions'  being  partly  over- 
lapped by  the  trapezius. 

It  arises  l)y  aponeurotic  fibers  from  the  spinous  processes  of  the 
five  or  six  lower  dorsal  and  the  lumljar  vertebrae.  Below  the  aponeu- 
rotic origin  of  the  latissimus  dorsi  is  intimately  blended  with  the 
aponeurosis  that  covers  the  erector  spinfe;  the  muscle  also  arises 
from  the  back  part  of  the  outer  lip  of  the  crest  of  the  ilium  and  by 
three  or  four  slips  from  the  external  surface  of  the  lower  ribs.  From 
this  extensive  origin  the  fibers  all  converge,  and  at  the  angle  of  the 
scapula  they  fonn  a  thick,  flat,  fleshy  muscle,  which,  making  a  half- 
turn  upon  itself,  passes  upward,  in  front  of  the  teres  major,  and  is 
attached  by  a  narrow,  flat,  aponeurotic  tendon  to  the  inner  lip  of 
the  bicipital  groove  of  the  luimerus.  The  tendon  of  the  latissimus 
dorsi  and  the  teres  major  form  the  lower  border  of  the  posterior 
walls  of  the  axilla. 


334  ABDOMEN  AND  BACK. 

Second  Layer  of  Muscles  : 

Levator  anguli  scapulge. 

Eliomboideus -^  .,. 

[  Minor. 

The  Levator  Anguli  Scapulce  is  located  in  the  side  of  the  neck 
and  the  ujoper  dorsal  region.  It  arises  by  tendinous  slips  from  the 
tubercles  on  the  transverse  processes  of  the  four  upper  cervical  ver- 
tebrae; passing  down  the  side  of  the  neck,  it  is  attached  to  the  upper 
part  of  the  inner,  or  vertebral,  border  of  the  scapulse. 

The  Rho'mhoids  are  two  flat  muscles  placed  one  above  the  other, 
both  lying  upon  the  same  plane  and  really  forming  one  broad,  flat 
muscle.  Internally  they  are  attached  to  the  spinous  processes  of 
the  last  cervical  and  four  or  five  upper  dorsal  vertebrse,  and  exter- 
nally to  the  vertebral  border  of  the  scapula. 

Third  Layer  of  Muscles. — Splenius;  serratus  posticus,  supe- 
rior and  inferior. 

The  Splenius  is  located  in  the  back  of  the  neck  and  upper  dorsal 
region,  reaching  from  the  occiput  downward  as  far  as  the  sixth  dorsal 
vertebrae  below. 

The  Serratus  Posticus. — The  superior  and  inferior  are  two  thin, 
fiat  muscles,  the  superior  being  located  in  the  upper  dorsal  region, 
the  inferior  in  the  lower  dorsal  ard  lumbar  regions. 

The  Muscles  of  the  Fourth  Layer  are  numerous  and  have 
a  longitudinal  direction,  reaching  upward,  alongside  of  the  spinal 
column,  from  the  sacrum  as  far  as  the  occiput.  The  muscles  of  this 
group,  except  the  erector  spinae,  are  of  but  little  importance  sur- 
gically. 

The  Erector  Spinse  below,  in  the  lumbar  region,  forms  a  large 
musculo-tendinous  mass,  which  fills  in  the  space  on  either  side  of 
the  lumbar  part  of  the  spinal  column,  being  superimposed  upon  the 
quadratus  lumborum  in  this  region.  From  the  lumbar  region  the 
erector  spinse  is  continued  upward  into  the  dorsal  region.  In  the 
dorsal  region  this  muscle  divides  into  a  number  of  processes,  each 
of  which  receives  a  difl:erent  name  and  is  described  as  a  separate 
muscle.  The  erector  spinse  below,  in  the  lumbar  region,  is  covered 
by  a  dense  aponeurotic  structure :  the  posterior  layer  of  the-  lumbar 
fascia.  The  muscle  arises  from  the  back  part  of  the  iliac  crest  and, 
through  its  aponeurosis,  from  the  posterior  surface  of  the  sacrum 
and  from  the  spinous  processes  of  the  lumbar  and  two  or  three  lower 


BACK.  335 

dorsal  vertebra?.  The  erector  spinas  is  included  between  the  poste- 
rior and  middle  layers  of  the  lumbar  fascia.  The  quadratus  lum- 
borum  lies  beneath  the  erector  spinse. 

In  the  lumbar  region  the  erector  spinse  forms  a  well-marked 
muscular  mass,  and  its  outer  edge  is  an  important  guide  in  cuttirg 
down  upon  the  kidney. 

The  Muscles  of  the  Fifth  Layee  are  numerous,  and  are  made 
up,  for  the  most  part,  of  longitudinal  strips  that  connect  adjoining 
vertebra  to  each  other.  They  are  all  more  or  less  continuous  with 
each  other,  but  receive  different  names  in  different  regions.  They 
are  lodged  in  the  groove  upon  either  side  of  the  spinous  processes, 
and  extend  from  the  sacrum  to  the  occiput. 

The  Quadratus  Lumborum  is  really  a  muscle  of  the  abdomen, 
forming  part  of  its  posterior  wall ;  it  is  quadrilateral  in  shape,  broad, 
and  thick.  It  fills  in  the  space  on  either  side  of  the  spinal  column 
from  the  last  rib  to  the  crest  of  the  ilium.  It  is  broader  below  at 
its  attachment  to  the  crest  of  the  ilium  than  above  at  its  insertion 
into  the  last  rib.  Its  outer  border  is  free  and  lies  more  external  than 
that  of  the  erector  spinae,  and  forms  an  important  surgical  guide. 

The  muscle  arises  by  aponeurotic  fibers  from  the  upper  part 
of  the  ilio-lumbar  ligament  and  from  the  adjacent  part  of  the  crest 
of  the  ilium  for  a  distance  of  about  two  inches.  From  this  origin 
the  muscle  passes  upward  and  is  inserted  into  the  inner  half  of  the 
lower  border  of  the  last  rib  and,  by  fleshy  slips,  to  the  transverse 
processes  of  the  four  upper  lumbar  vertebrre. 

The  muscle  is  inclosed  between  the  middle  and  anterior  layers 
of  the  lumbar  fascia,  and  lies  directly  beneath  the  erector  spinge, 
from  which  it  is  separated  by  the  middle  layer  of  the  lumbar  fascia. 

The  Lumbar  Fascia. — In  the  lumbar  region  there  is  a  strong 
aponeurotic  structure  called  the  lumbar  fascia;  it  is  through  this 
fascia  that  the  transversalis  muscle  is  connected  with  the  spine. 
The  lumbar  fascia  is  usually  described  as  consisting  of  three  layers 
(see  Fig.  89).  The  anterior  layer  is  rather  thin,  covers  the  front 
surface  of  the  quadratus  lumborum  muscle,  and  is  attached  inter- 
nally to  the  anterior  aspect  of  the  transverse  processes  of  the  lumbar 
vertebrae;  above,  this  layer  of  the  fascia  is  attached  to  the  lower 
border  of  the  last  rib,  where  it  constitutes  the  ligamentum  arcuatum 
externum.  The  middle  layer  of  the  lumbar  fascia  is  strong,  is  at- 
tached to  the  apices  of  the  transverse  processes  of  the  lumbar  ver- 
tebrae, and  is  placed  between  the  quadratus  lumborum  and  erector 


336  ABDOMEN  AND  BACK. 

spinse  muscles.  The  posterior  layer  of  the  lumbar  fascia  is  attached 
to  the  apices  of  the  spinous  processes  of  the  lumbar  vertebrge ;  it 
forms  the  posterior  aponeurotic  covering  of  the  erector  spinse,  and 
is  blended  with  the  aponeurosis  of  origin  of  the  latissimus  dorsi.  At 
the  outer  border  of  the  quadratus  lumborum  the  three  layers  of  the 
lumbar  fascia  unite  to  form  a  single  aponeurotic  layer,  through  which 
the  transversalis  muscle  is  connected  with  the  spinal  column. 

The  Psoas  and  Iliacus  Muscles.— In  the  back  of  the  abdomen, 
lying  one  upon  either  side  of  the  spinal  column,  is  the  psoas  muscle. 
It  arises  by  slips  from  the  transverse  processes  and  bodies  of  the  last 
dorsal  and  the  lumbar  vertebrse,  and  passing  downward  joins  with 
the  iliacus. 

The  iliacus  muscle  occupies  the  iliac  fossa,  taking  its  origin 
there,  and,  together  with  the  psoas,  passes  out  of  the  abdomen  under 
Poupart's  ligament  to  be  attached  to  the  lesser  trochanter  of  the 
femur  and  to  the  surface  of  the  bone  immediately  below  this. 

The  psoas  and  iliacus  are  covered  by  a  fascia,  the  iliac  fascia. 
This  is  simply  a  part  of  the  general  transversalis  fascia  of  the  ab- 
domen. That  part  which  covers  the  psoas  muscle  is  thickened  above, 
where  it  is  Imown  as  the  liganaentum  arcuatum  internum;  laterally, 
beyond  the  edge  of  the  psoas  muscle,  this  fascia  is  continuous  with 
that  which  covers  the  quadratus  lumborum:  the  anterior  layer  of 
the  lumbar  fascia.  The  iliac  fascia  covers  the  iliacus  muscle  also, 
and  is  attached  to  the  crest  of  the  iliu.m  and  the  brim  of  the  pelvis, 
and  to  Poupart's  ligament  except  where  the  femoral  vessels  pass 
down  into  the  thigh.  In  this  situation  the  fascia  is  continued  down- 
ward, under  Poupart's  ligament,  behind  the  vessels  into  the  thigh, 
covering  the  anterior  surface  of  the  psoas-iliacus  muscle. 

The  parietal  peritoneum  is  spread  out  over  the  inner  surface 
of  the  posterior  wall  of  the  abdomen.  The  kidney,  incased  in  its 
capsule  of  fat,  lies  between  this  layer  of  the  peritoneum  and  the 
fascia  which  covers  the  quadratus  lumborum  muscle. 

The  Spinal  Column,  etc. — ^The  spinal  column  is  made  up  of  the 
vertebrge  and  intervertebral  pads,  the  sacrum,  and  the  coccyx;  it  is 
located  at  a  considerable  depth  from  the  surface  of  the  body.  The 
spinal  column  gives  solidity,  combined  with  flexibilit}^,  to  the  trunk, 
and  furnishes  a  canal  to  contain  and  protect  the  spinal  cord. 

We  may  palpate  the  body  of  the  first  cervical  vertebra,  the  atlas, 
through  the  mouth,  its  anterior  tubercle  lying  just  behind  the  soft 
palate;  those  vertebrae  which  lie  below  this  down  as  far  as  the  fifth 


BACK.  337 

cervical  may  also  be  palpated  through  the  mouth.  Lower  in  the 
neck  and  in  the  dorsal  region  palpation  of  the  bodies  of  the  vertebrge 
is  impossible.  The  bodies  of  the  lumbar  vertebra  can  be  felt  through 
the  abdomen^  especially  in  thin  persons.  The  sacrum  and  coccyx 
may  be  palpated  thro>igh  the  rectum. 

The  laminse  meet  behind,  in  the  middle  line,  to  form  the  spinous 
processes  and  to  complete  the  canal  which  contains  the  spinal  cord. 

In  the  cervical  and  lumbar  regions  the  spaces  l^etween  the 
lamina  are  broad,  and  a  knife-blade  might  easily  be  introduced 
through  these  into  the  spinal  canal.  This  could  not  be  so  readily 
done  in  the  dorsal  region,  however,  where  the  laminae  and  spines 
overlap  each  other  like  the  shingles  on  a  roof. 

The  spaces  between  the  laminae  are  occupied  by  the  ligamenta 
subflava,  which  seiTe  to  complete  the  canal  and  even  it  out  upon 
its  inner  aspect. 

The  bodies  of  the  vertebrae  are  joined  to  each  other  by  the  ante- 
rior and  posterior  common  ligaments;  the  posterior  common  liga- 
ment, besides  connecting  the  bodies  of  the  vertebrae  with  each  other, 
also  serves  to  even  out  the  irregularities  upon  the  internal  aspect  of 
the  canal.  The  spines  of  the  vertebras  are  connected  with  each  other 
by  ligaments :  the  interspinous  and  the  supraspinous. 

The  spinal  column  presents  three  curves  in  the  sagittal  direc- 
tion, antero-posterior,  and  one  lateral  with  the  concavity  toward  the 
left  (aorta). 

Fractures  of  the  spine  usually  involve  the  fifth  and  sixth  cer- 
vical, last  dorsal,  and  first  lumbar  vertebrae,  and  are  usually  caused 
by  indirect  violence,  the  curved  parts  of  the  spine  being  bent  beyond 
the  limit  of  their  elasticity. 

The  spinal  canal  is  widest  in  the  neck  and  triangular  upon  sec- 
tion ;  narrower  in  the  dorsal  region  and  circular  upon  section.  It  is 
narrowest  at  the  level  of  the  ninth  dorsal.  From  the  eleventh  dorsal 
it  becomes  wider  again.  In  the  sacrum  it  is  flattened  from  before 
backward  and  terminates  upon  the  posterior  surface  of  this  bone. 

The  spinal  canal  shows  a  series  of  openings — intervertebral — 
upon  either  side,  just  behind  the  bodies,  for  the  passage  of  nerves 
and  vessels  to  and  from  the  canal.  The  contents  of  the  canal  are 
well  protected.  It  is  an  uncommon  accident  for  an  instrument  to 
penetrate  into  the  canal,  and  unusual  force  is  required  to  injure  the 
cord  inclosed  within  these  bony  walls. 

Contained  within  the  canal  is  the  spinal  cord,  which  is  much 

22 


338  ABDOMEN  AND  BACK. 

smaller  and  shorter  than  the  canal;  the  spinal  cord  commences  at 
the  upper  border  of  the  posterior  arch  of  the  atlas,  where  it  is 
continuous  with  the  medulla,  and  terminates  below  in  the  conus 
terminalis  on  a  level  with  the  lower  border  of  the  first  Imubar  ver- 
tebra. From  the  conus  terminalis  the  cord  is  prolonged  still  farther 
do-RTiward  as  the  filum  terminale. 

The  spinal  cord,  as  it  lies  within  the  canal,  is  inclosed  by  the 
dura  and  pia  mater.  The  dura  mater  of  the  spinal  canal  is  con- 
tinuous with  the  dura  mater  that  lines  the  interior  of  the  skull, 
and  is  adherent  to  the  margin  of  the  foramen  magnum.  Here  it 
splits  into  two  layers,  the  external  of  which  is  applied  to  the  inner 
aspect  of  the  spinal  canal  as  a  lining  membrane,  periosteum,  whereas 
the  other,  the  inner  layer,  forms  a  loose,  sack-like  envelope  for  the 
cord,  the  dura  mater  proper,  and  is  continued  all  the  way  down 
to  the  coccyx,  where  it  is  blended  with  the  periosteum  of  that  bone. 
Between  these  two  layers  there  is  a  space  in  which  veins  and  arteries 
ramify  and  into  which  hemorrhage  may  take  jDlace.  Each  nerve, 
at  its  exit  from  the  spinal  canal,  has  prolonged  upon  it  a  tubular 
process,  which  is  derived  from  the  dura  and  pia  mater. 

Beneath  this  dura  mater  sheath  is  the  pia  mater,  a  reticular 
structure  like  that  which  invests  the  brain;  the  outer  surface  of 
the  pia  is  known  as  the.  arachnoid,  and  the  inner,  which  is  applied 
directly  to  the  surface  of  the  cord,  is  known  as  the  pia  mater 
proper  and  carries  the  vessels  which  penetrate  into  the  substance 
of  the  cord  to  supply  it. 

Between  the  two  surfaces  of  the  pia  there  is  a  space,  which 
is  called  the  subarachnoid  space,  and  which  is  subdivided,  cut  up, 
by  numerous  trabeculse  into  a  net-work  of  small  spaces.  In  the 
subarachnoid  space,  between  the  two  layers  of  the  pia,  the  cerebro- 
spinal fluid  is  found.  From  the  pia  mater  laterally,  between  the 
roots  of  the  nerves,  there  arises  a  longitudinal  septum  which  is 
attached  to  the  inner  surface  of  the  dura  mater  by  a  number  of 
processes.  The  line  of  origin  from  the  pia  is  continuous.  The  line 
of  attachment  to  the  dura  mater  is  interrupted.  This  is  known  as 
the  ligamentmn  dentatum. 

The  surfaces  of  the  dura  and  the  pia  mater  (arachnoid)  are 
not  joined  to  each  other  except  for  occasional  strands  of  connective 
tissue  that  unite  them  here  and  there.  The  space  between  the 
dura  and  pia  mater  is  known  as  the  subdural  space. 

Each  nerve-root  is  provided  with  an  envelope  consisting  of  a 
process  of  the  pia  and  dura. 


OPERATIONS  UPON  THE  ABDOMEN.  339 

Arteries  that  siipply  the  cord  consist  of  l)ranchcs  I'l'om  the  verte- 
bral, intercostals,  lumbar,  and  lateral  sacral ;  all  alono;  the  spinal 
column  these  vessels  pass  through  the  intervertebral  foramina  to  supply 
the  coverings  and  the  cord. 

Veins,  in  the  fomi  of  plexuses,  are  found  on  the  front  and 
back  of  the  cord,  within  the  canal,  between  the  two  layers  of  the 
dura,  or,  better,  between  the  dura  proper  and  the  periosteum. 

OPERATIONS    UPON    THE    ABDOMEN. 

Laparotomy. — Incision  into  the  abdomen.  This  operation  is 
undertaken  for  the  purpose  of  relieving  some  condition  previously 
diagnosticated  or  of  exploration  in  conditions  of  doubtful  diag- 
nosis. Abdominal  incision  is.  in  almost  all  instances,  more  or  less 
exploratory,  since  it  is  rarely  possible  to  be  positive  as  to  the  exact 
nature  of  the  conditions  that  exist  within  the  abdomen.  Tn  most 
eases,  however,  an  approximate  diagnosis  will  have  been  made  and 
the  incision  is  placed,  and  the  preliminary  preparations  made  ac- 
cordingly. 

Pkepaeatiox  of  the  Patient. — The  preparation  of  the  patient 
is  important.  The  evening  before  operation  the  patient,  if  the 
conditions  permit,  is  given  a  warm  tub-bath.  He  is  then  put  to 
bed  and  his  ahdomen  is  shaved  and  scrubbed  with  a  soft,  flesh 
brush  or  a  square  of  gauze,  using  tincture  of  green  soap  and  water. 
This  scrubbing  process  should  be  thorough,  devoting  special  atten- 
tion to  folds  in  the  skin  and  to  the  umbilicus,  but  it  should  not 
be  too  vigorous  nor  should  it  be  done  with  a  harsh  brush.  It  is 
desirable  that  the  skin  be  not  scratched  or  abraded.  i\fter  the 
scrubbing  process  has  been  completed  the  abdomen  is  wiped  dry 
with  gauze  pads.  The  abdomen  is  then  wiped  successively  with 
sterile  gauze  pads,  first  wet  with  ether,  and  then  wet  with  alcohol. 
Finally  the  abdomen  is  swabbed  with  a  gauze  wipe  wet  with  bichlo- 
ride solution,  1  in  2000,  and  a  towel  wrung  out  in  the  same  solu- 
tion is  applied  to  the  abdomen  and  held  in  place  with  an  abdominal 
bandage,  and  left  thus  until  the  patient  is  transferred  to  the 
operating  table.  After  the  patient  has  been  placed  upon  the  table 
and  anesthetized,  the  abdominal  bandage  and  towel  are  removed 
and  the  abdomen  is  again  scrubbed  and  washed  with  ether,  alcohol, 
and  bichloride  solution.  The  stomach,  bowels,  and  bladder  should 
be  empty  at  the  time  of  operation.  If  conditions  permit,  the  bowels 
should  be  emptied  by  the  administration  of  laxatives  given  on 
one    or    on    several    evenings    preceding    the    operation.      A    satis- 


340  ABDOMEN  AND  BACK. 

factory  plan  is  to  give  a  dose  of  castor  oil,  half  to  one  ounce,  the 
evening  before  the  operation.  A  soapsuds  enema  is  given  about 
three  hours  before  the  time  set  for  the  operation,  and  is  repeated 
until  the  return  is  clear.  The  bladder  is  emptied  either  voluntarily 
or  by  catheter  before  the  patient  is  carried  to  the  operating  room. 
The  stomach  will  be  empty  if  the  patient  has  been  fasting  for  ten 
or  twelve  hours  previous  to  the  time  of  operation.  If  the  operation 
contemplates  opening  the  stomach  the  teeth  should  be  carefully  brushed 
twice  or  three  times  daily,  and  an  antiseptic  mouth-wash  used  fre- 
quently for  several  days  prior  to  the  operation.  In  these  stomach 
cases  the  patients  should  commence  the  systematic  cleansing  of  the 
teeth  and  mouth  several  days  before  the  operation,  and  during  this 
period  only  fluid  foods,  and  none  but  those  that  have  been  boiled  and 
pure  water  are  allowed.  The  stomach  is  washed  out  finally  just  before 
the  patient  is  angesthetized. 

Occasionally  in  exceptional  and  emergency  cases,  as,  for  exam- 
ple, when  operating  for  perforated  gastric  or  intestinal  ulcer;  sus- 
pected acute  gangrenous  appendicitis,  gun-shot  wounds  and  rupture 
of  the  intestine,  etc.,  it  will  be  unwise  or  impossible  to  carry  out 
some  of  the  preparations  described  above.  The  operator  will  have 
to  be  content  with  shaving  and  thorough  scrubbing  and  disinfection 
of  the  abdomen  immediately  before  proceeding  with  the  operation 
or  the  field  of  operation  may  be  very  satisfactorily  prepared  by  thorough 
rubbing  with  benzin  and  painting  with  a  5  per  cent,  iodine.  In 
these  cases  neither  laxative  nor  enema  should  be  given  before  the 
operation. 

iNCisioisr. — The  position  of  the  incision  varies  according  to  the 
location  of  the  organ  that  is  to  be  exposed.  It  is  placed  most  commonly 
in  the  middle  line,  above  or  below  the  umbilicus,  but  it  may  be  more 
convenient  to  place  it  elsewhere  if  it  is  desired  to  reach  certain  of  the 
abdominal  organs,  as,  for  example,  the  gall-bladder,  appendix,  etc. 
Where  possible  the  abdomen  should  be  opened  without  dividing  any 
of  the  fleshy  fibers  of  muscles,  using  the  blunt  method  of  penetrating 
the  muscle,  splitting  between  the  fibers  with  the  handle  of  the  knife 
or  with  the  fingers,  so  that  nerve  branches  that  ramify  in  the  substance 
of  the  muscle  will  be  pushed  upward  or  downward  out  of  the  way  and 
not  cut.  It  is  important  to  avoid  division  of  the  nerves  that  supply  the 
abdominal  muscles.  In  those  cases  where  the  incision  is  purely  ex- 
plorator3^  it  is  placed  in  or  near  the  middle  line,  either  above  or  below 
the  umbilicus.    In  the  beginning  the  incision  should  not  be  any  longer 


OPERATIONS  UPON  THE  ABDOMEN.  341 

than  is  required  to  permit  the  introduction  of  the  fingers  and  the 
necessary  intra-abdominal  examination.  The  incision  can  be  extended 
subsequently  as  may  be  indicated,  and  to  a  sufficient  degree  to  permit 
of  the  necessary  operative  work.  In  very  fat  patients  the  incision  in 
the  skin  and  fat  layers  is  made  longer,  so  as  to  give  better  access  to 
the  deeper  layers  of  the  abdominal  -wall. 

Median  Incisiox. — The  incision  in  the  middle  line  is  carried 
through  the  skin  and  fat  down  to  the  aponeurosis,  linea  alba,  with 
one  or  two  sweeps  of  the  knife.  Arterial  and  venous  branches, 
which  are  severed,  are  clamped,  but  need  not  be  ligatured  at  once. 
Usually  the  hemorrhage  from  these  small  branches  will  have  ceased 
when  the  clamps  are  removed  later  on  in  the  course  of  the  opera- 
tion, and  it  will  not  be  necessary  to  tie  them.  The  aponeurotic  layer, 
linea  alba,  is  divided  with  the  knife  or  sharp-pointed  angular  scissors 
cutting  between  the  edges  of  the  recti.  Below  the  umbilicus,  where 
the  edges  of  the  recti  lie  close  together,  the  edges  of  the  muscles  are 
usually  exposed  and  recognized.  Above  the  umbilicus  the  edges  of 
the  recti  are  more  widely  separated,  and  we  may  cut  through  the 
linea  alba  between  the  muscles  without  exposing  their  edges. 

After  the  aponeurosis,  linea  alba,  has  been  divided,  the  fascia 
transversalis  is  exposed  to  view.  When  this  layer  is  incised  we 
enter  the  loose  connective  tissue  and  fat  layer,  the  so-called  pre- 
peritoneal fat  layer.  This  layer  is  scraped  or  torn  through  with 
the  finger  or  handle  of  the  knife,  or  snipped  with  the  knife,  and 
the  peritoneal  layer  proper  is  exposed.  The  peritoneal  layer  is  picked 
up  with  two  mouse-tooth  forceps  and  incised  between  these.  Care 
is  exercised,  in  picking  up  the  peritoneal  layer,  not  to  include  the 
underlying  gut  in  the  grip  of  the  forceps.  Even  if  the  gut  is  not 
adherent  it  often  floats  up  so  close  to  the  peritoneum  that  there 
is  danger  of  catching  it  up  with  the  forceps  and  dividing  it.  At 
times,  especially  in  thin  patients,  the  pre-peritoneal  fat  layer  is 
very  thin  or  almost  absent,  and  the  fascia  transversalis  and  peri- 
toneal layer  may,  under  these  circumstances,  be  divided  as  a  single 
layer.  The  edges  of  the  small  opening  which  has  been  made  in 
the  peritoneum  are  seized  with  artery  clamps,  one  on  each  side, 
and  the  finger  is  introduced  and  the  incision  enlarged,  cutting  upon 
the  finger  as  a  guide  with  the  blunt-pointed  scissors.  If  the  incision 
is  below  the  umbilicus,  it  is  well  to  incise  the  peritoneal  layer  in 
the  upper  part  of  the  incision,  so  as  to  avoid  the  bladder  in  case 
it  may  have  been   drawn  up   into  the  abdomen  by  a  tumor  whith 


342  ABDOMEN  AND  BACK. 

rises  out  of  the  pelvis  above  the  level  of  the  symphysis.  If  it 
becomes  necessary  to  prolong  the  incision  in  the  middle  line^  upward 
or  downward,  beyond  the  nmbiliciis,  this  is  done  by  carrying  it  to 
the  left  of  the  umbilicus  rather  than  to  the  right,  in  order  to  avoid 
the  round  ligament  of  the  liver  and  its  falciform  fold  of  peritoneum. 

Lateeal  Vertical  Incisions  are  preferred  to  those  that  pass 
through  the  middle  line,  linea  alba.  They  are  made  parallel  with  the 
linea  alba,  above  or  below  the  level  of  the  umbilicus.  These  incisions 
are  sometimes  made  quite  close  to  the  middle  line,  exposing  the  inner 
edge  of  the  rectus  muscle.  The  edge  of  the  muscle  is  drawn  outward 
away  from  the  middle  line  to  permit  of  the  incision  being  made  through 
ihe  posterior  layer  of  the  rectus  sheath,  fascia  transversalis,  and  peri- 
toneum. This  incision  is  preferred  by  many  surgeons  and  has  several 
distinct  advantages,  chief  among  which  is  the  fact  that  the  rectus 
muscle  is  not  injured  nor  is  its  nerve  supply  interfered  with,  and  the 
linea  alba  is  not  cut  through.  When  the  incision  is  closed  the  several 
aponeurotic  layers  can  be  sutured  separately,  and  the  edge  of  the 
muscle  returns  into  place  and  forms  a  strong  buttress  against  subse- 
quent hernia. 

Incisions  are  frequently  employed  which  run  parallel  with,  but 
more  or  less  distant  from,  the  middle  line,  penetrating  between  the 
fleshy  fibers  of  the  rectus  muscle.  In  the  loAver  part  of  the  abdomen 
this  incision  is  employed  in  order  to  reach  the  appendix,  uterus  and 
appendages,  colon,  sigmoid  flexure,  etc.,  and  affords  very  satisfac- 
tory access  to  these  organs.  After  the  fascia  transversalis  has  been 
divided  the  deep  epigastric  artery  and  vein  are  exposed  in  the 
bottom  of  the  incision,  and  must  be  avoided  or  ligated.  In  the  upper 
part  of  the  abdomen  the  incision  through  the  middle  or  through 
the  outer  part  of  the  rectus,  is  employed  to  expose  the  gall-bladder, 
liver,  pylorus,  spleen,  etc.  In  penetrating  between  the  flbers  of  the 
rectus,  it  is  desirable  to  tear  bluntly  up  and  down  with  the  handle  of 
the  knife  or  with  tlie  fingers,  so  as  not  to  divide  any  of  the  nerve 
branches  that  supply  the  portion  of  the  muscle  that  lies  to  the  inner 
side  of  the  incision.  If  the  nerve  branches  are  divided,  the  por*tion 
of  the  muscle  to  the  inner  side  of  the  incision  is  likely  to  atrophy,  and 
thus  the  development  of  a  ventral  hernia  is  invited. 

The  Oblique  Incision  Below  and  Parallel  with  the  Free 
Border  of  the  Ribs  is  used  by  some  operators  for  the  purpose  of 
exposing  the  gall-bladder,  liver,  and  stomach.  When  this  incision 
is  employed  in  gastrostomy,  it  is  carried  down  through  the  muscle 


OPERATIONS  UPON  THE  ABDOMEN.  343 

layers,  separating  bluntly  between  the  fibers  of  the  internal  oblique 
and  the  transversalis,  gridiron  incision. 

The  Gridiron  Incision  of  McBurney  is  employed  whenever 
possible  in  operations  upon  the  appendix,  and  may  be  used  upon 
the  left  side  for  colostomy.  In  this  incision  the  aponeurosis  and 
muscle  layers  are  not  cut;  they  are  separated  bluntly  between  the 
fibers  along  the  course  of  their  direction  with  the  fingers  or  with 
the  handle  of  the  knife.     (See  page  477.) 

The  Battle  Incision  is  vertical  and  placed  in  the  lower  part  of 
the  abdomen,  to  the  inner  side  of  the  linea  semilunaris.  It  is 
employed  to  expose  the  appendix,  and  sometimes  the  tubes  and 
ovaries.  After  the  anterior  layer  of  the  rectus  sheath  has  been 
incised  the  rectus  muscle  is  exposed.  The  rectus  is  not  cut  through, 
but  is  drawn  over  toward  the  middle  line,  so  as  to  expose  the  poste- 
rior layer  of  the  sheath  of  the  muscle.  The  posterior  layer  of  the 
rectus  sheath  is  incised  along  a  line  external  to  that  of  the  incision 
in  the  anterior  layer  of  the  sheath.  In  closing  this  incision  the 
several  layers  are  sutured  separately,  and  the  uninjured  muscle 
returns  to  its  original  place  and  forms  a  strong  bulwark  between 
the  lines  of  incision  in  the  anterior  and  posterior  layers  of  its 
sheath.  The  deep  epigastric  vessels  are  seen  crossing  the  incision, 
after  the  posterior  layer  of  the  rectus  sheath  and  transversalis 
fascia  have  been  incised.  The  vessels  may  be  clamped  and  ligated 
before 'they  are  cut,  or  they  may  be  pulled  over  to  one  side  and 
not  divided. 

Transverse  Incision  of  the  abdominal  wall,  entailino-  cross- 
division  of  the  muscles,  should  be  avoided  whenever  possible.  This 
incision  reaches  from  near  the  tip  of  the  twelfth  rib  fonvard,  around 
the  side  of  the  abdomen  toward  the  umbilicus.  It  is  employed  for 
removal  of  large  tumors  of  the  kidney  and  spleen,  and  for  gaining 
access  to  the  pancreas. 

KrsTNER  AND  Pfannenstiel  Incision  may  be  occasionally 
employed  with  advantage,  where  much  room  is  not  required,  for 
gynecological  operations,  suspension  of  uterus,  operations  upon 
ovaries,  etc.  It  is  not  practical  wliere  large  tumors  are  to  be 
removed.  The  incision  passes  across  the  lower  part  of  the  abdo- 
men, reaching  from  the  outer  edge  of  one  rectus  to  the  outer  edge 
of  the  other.  The  incision  is  slightly  curved,  with  the  convexity 
downward,  just  above  the  s}Tnphysis.  The  incision  penetrates  the 
skin  and  fat,  and  exposes  the  aponeurosis  covering  the  rectus  mus- 


344  ABDOMEN  AND  BACK. 

cles.  The  aponeurosis  is  divided  in  a  transverse  direction,  and 
detached  upward  and  downward  from  the  surface  of  the  recti. 
Penetrating  hetween  the  edges  of  the  rectus  muscles  through  the 
linea  alba,  the  fascia  transversalis  and  peritoneum  are  incised  in 
the  usual  way,  and  the  abdomen  entered.  The  incision  is  closed 
layer  by  layer.  First  the  edges  of  the  peritoneum  and  transversalis 
fascia  are  united  with  a  continuous  suture  of  plain  catgut,  then  the 
edges  of  the  recti  are  approximated  with  several  interrupted  sutures 
of  plain  catgut.  The  edges  of  the  aponeurosis  are  united  with  a 
continuous  suture  of  chromic  catgut,  and  finally  the  skin.  The 
scar  is  not  conspicuous,  and  is  partly  hidden  by  the  hair  growth 
above  the  pubes.  The  chief  advantage  of  the  incision  is  the  absence 
of  a  prominent  abdominal  cicatrix. 

ExAMiNATioisr  OF  ABDOMINAL  ORGANS,  Etc. — After  the  abdomen 
has  been  opened,  the  fingers,  or  the  hand,  are  introduced  for  the 
purpose  of  exploration.  It  is  necessary  to  be  systematic  in  exami- 
nation and  gentle  in  manipulation.  Care  must  be  exercised  in 
separating  adhesions.  Much  unnecessary  hemorrhage,  and  maybe 
tearing  of  hollow  organs,  may  result  from  violence  in  this  regard. 
In  very  young  children  it  is  easy  to  tear  the  gut  away  from  its 
delicate  mesentery. 

The  organ,  which  is  the  object  of  operation,  is  drawn  into  the 
incision  or  out  upon  the  abdomen  if  possible.  Access  to  the  various 
abdominal  organs  is  assisted  very  materially  by  position.  The 
pelvic  organs,  by  Trendelenburg;  the  gall-bladder,  ducts,  etc.,  by 
the  use  of  the  Eobson  cushion  under  the  lower  dorsal  region  and 
by  raising  the  head  end  of  the  table,  etc.  Gauze  pads  of  large  size 
are  tucked  into  the  incision  and  about  the  organ  which  is  to  be 
operated  upon  to  protect  the  peritoneal  cavity  against  the  entrance 
of  blood  and  various  discharges.  These  abdominal  pads  -should  be 
provided  with  tapes  and  artery  clamps  attached  and  carefully 
accounted  for.  Smaller  pads  employed  as  intra-abdominal  wipes 
should  not  be  used  loose;  they  are  less  likely  to  be  overlooked  and 
left  in  the  abdomen  if  used  on  holders.  Gauze  wipes  and  lapar- 
otomy pads,  artery  clamps  and  parts  of  broken  artery  clamps,  have 
been  left  in  the  peritoneal  cavity.  Operations  that  involve  resec- 
tion of  bowel,  etc.,  should  be  done,  as  far  as  possible,  with  the 
parts  outside  upon  the  abdomen,  and  after  the  operation  has  been 
completed,  and  before  returning  the  sutured  organs  into  the  abdomi- 
nal cavity,  they  should  be  thoroughly  cleansed  by  swabbing  them  with 
a  gauze  wipe  wet  with  very  hot  saline  solution. 


OPERATIONS  UPON  THE  ABDOMEN.  345 

Before  proceeding  to  closure  of  the  incipion,  the  operator  should 
assure  himself  that  all  hemorrhage  has  ceased  or  has  been  controlled, 
and  that  the  abdominal  cavity  has  been  wiped  dry  of  blood  and 
other  fluids. 

Closure  of  the  Incision. — It  is  desirable  to  obtain  primary 
union — union  which  is  firm  and  secure  from  the  danger  of  subse- 
quent hernia.  The  incision  should  be  dry  and  free  from  oozing  before 
proceeding  to  close.    There  are  several  methods  of  closure. 

Through-and-Througii  Suture. — The  incision  is  closed  by  a 
number  of  interrupted  sutures  of  heavy  silk  or  silk-worm  gut. 
These  sutures  pierce  all  the  layers  of  the  abdominal  wall.  This 
method  of  closure  has  many  disadvantages,  and  should  not  be  used 
except  in  cases  where  great  haste  in  completing  the  operation  is 
indicated.  Where  this  plan  is  employed  the  edges  of  the  corre- 
sponding layers  are  not  brought  into  sufficiently  accurate  appo- 
sition, and  even  when  primary  union  results  there  is  more  likeli- 
hood of  a  subsequent  yielding  of  the  cicatrix  and  consequent  ven- 
tral hernia.  There  is  frequently  failure  to  obtain  primary  union. 
The  sutures  penetrate  the  skin  and  are  therefore  more  apt  to  be- 
come infected.  Each  suture  in  its  course  pierces  all  of  the  layers 
of  the  abdominal  wall,  including  the  peritoneum,  and  thus  presents 
a  loop  upon  the  inner  surface  of  the  peritoneum,  within  the  abdomi- 
nal cavity.  If  the  sutures  become  infected  the  process  readily  extends 
along  the  course  of  the  sutures  into  the  abdominal  cavity. 

Many  of  the  disadvantages  of  the  through-and-through  suture 
may  be  obviated  by  first  suturing  the  peritoneum  and  the  fascia 
transversalis  with  a  separate  continuous  suture  of  plain  catgut,  and 
then  introducing  the  interrupted  mass-sutures  of  silk,  silk-worm 
gut,  etc.,  which  penetrate  the  skin,  aponeurosis,  and  muscle  layers 
only.  By  this  method  closure  may  be  effected  quickly  and  without 
the  disadvantages  of  the  through-and-through  suture.  As  a  result 
of  the  separate  suture  of  the  peritoneum  and  fascia  transversalis, 
there  is  obtained  an  accurate,  smooth  union  of  the  peritoneal  layer. 
The  mass-sutures  that  secure  the  skin,  aponeurosis,  and  muscle 
may  be  applied  so  as  to  oppose  the  edges  of  the  corresponding  layers 
fairly  accurately,  and  they  have  not  the  great  fault  of  pene- 
trating the  peritoneal  layer  and  presenting  inside  within  the  peri- 
toneal cavity. 

Layer-by-Layer  Suture. — The  most  satisfactory  method  of 
closing   the   abdominal    incision   is   layer   by    layer.      The   edges    of 


346  ABDOMEN  AND  BACK. 

the  peritoneum  are  sewed  together  with  a  continuous  suture  of 
plain  catgut.  The  edges  of  the  fascia  transversalis  (and  posterior 
layer  of  the  sheath  of  the  rectus  in  some  parts  of  the  abdomen) 
are  included  with  the  peritoneum  in  this  suture  on  account  of  the 
strength  which  is  added  by  this  strong  layer.  The  edges  of  the 
muscle  are  brought  together  with  several  interrupted  sutures  of 
plain  catgut,  and  finally  the  edges  of  the  aponeurosis  are  united 
with  a  continuous  suture  of  chromic  catgut.  Some  surgeons  advise 
overlapping  the  edges  of  the  aponeurosis^  one  over  the  other.  The 
edges  of  the  skin  are  sutured  with  plain  catgut.  It  is  desirable  to 
use  the  intra-cuticular  suture  for  approximating  the  edges  of  the 
skin.  The  stitches  do  not  pierce  the  skin,  and  therefore  there  is 
much  less  likelihood  of  infection,  stitch  abscesses,  etc.,  and  greater 
probability  of  primary  union.  With  this  suture  the  resulting  scar 
is  very  much  diminished. 

Drainage. — Where  it  is  necessary  to  employ  drainage,  the 
incision  must  be  left  open  in  part.  Even  in  these  cases  the  through- 
and-through  method  of  suture  should  be  avoided.  The  several 
layers  can  be  sutured  separately,  as  described  in  the  layer-by-layer 
method,  leaving  the  lower  end  of  the  incision  where  the  drains 
■emerge  unsutured  or  the  edges  of  the  peritoneum  and  fascia  trans- 
versalis may  be  first  sewed  together  as  a  single  layer  with  a  con- 
tinuous suture  of  plain  catgut,  and  the  other  layers,  skin,  aponeu- 
rosis, and  muscle  then  approximated  with  a  sufficient  number  of 
interrupted  sutures  of  silk  or  silk-worm  gut.  These  sutures  include 
all  the  layers  of  the  abdominal  wall,  except  the  peritoneum  and 
fascia  transversalis  (and  posterior  layer  of  the  sheath  of  the  rectus 
in  certain  parts  of  the  abdominal  wall). 

If  it  is  necessary  to  leave  the  incision  partly  open  for  the 
purpose  of  drainage,  the  probability  of  subsequent  yielding  of  the 
cicatrix  and  development  of  hernia  is  greatly  increased.  The 
employment  of  drainage  should  be  limited  as  much  as  possible. 
Drainage  is  frequently  employed  unnecessarily.  The  peritoneum 
will  itself  take  care  and  dispose  of  a  limited  amount  of  infectious 
matter.  Drains,  when  used,  should  not  be  unnecessarily  bulky,  and 
should  be  made  to  emerge  at  the  lower  end  of  the  incision.  The 
rest  of  the  incision  can  be  carefully  sutured.  The  drains  should 
be  removed  as  early  as  possible.  They  will,  as  a  rule,  have  served 
their  purpose  at  the  end  of  forty-eight  hours,  when  they  can  be 
removed    and   replaced,   if   necessary,   by    a   narrow   strip    of   gauze. 


OPERATIONS  FOR  HERNIA,  ETC.  347 

OPERATIONS  FOR  UMBILICAL  AND  VENTRAL  HERNIA,  ETC. 

Umbilical  Hernia. — By  umbilical  hernia  is  meant  a  protrusion  of 
the  abdominal  contents  through  the  imibilical  ring.  The  umbilical 
ring  is  an  aperture  which  is  present  in  the  foetus.  Through  it  the 
foetal  channels  (vitelline  duct  and  pedicle  of  the  allantois)  and  the 
flmbilical  arteries  and  vein  pass  to  and  from  the  placenta.  At 
birth,  under  normal  conditions,  the  abdominal  walls  will  have  grown 
together  tightly  around  the  root  of  the  umbilical  cord,  and  the 
ioetal  umbilical  ring  is  thus  reduced  to  a  size  which  is  just  sufficient 
to  accommodate  the  structures  that  comprise  the  umbilical  cord. 
If  the  cord  is  examined  at  birth  it  will  be  observed  that  the  skin 
is  continued  from  the  alxlomen  upward  around  the  root  of  the  cord 
for  a  short  distance  to  become  continuous  with  the  amniotic  layer 
which  forms  the  outer  envelope  or  sheath  of  the  cord.  Where  the 
skin  joins  the  amniotic  layer  upon  the  root  of  the  cord,  there  is  a 
well  marked,  irregular  line  of  demarcation. 

The  subject  of  umbilical  hernia  is  considered  in  detail  under 
three  headings,  as  follows : — 

1.  Congenital  Umbilical  Hernia. 

2.  Infantile  Hernia. 

3.  Umbilical  Heiiiia  in  Adults. 

Congenital  Umbilical  Hernia. — Hernia  funiculi  umbilicalis; 
hernia  into  the  root  of  the  umbilical  cord.  This  is  a  congenital  hernia 
in  the  strict  sense.  It  has  its  origin  during  the  foetal  period,  and  it 
is  present  at  birth. 

The  condition  is  rare — seen  once  in  three  or  four  thousand 
births.  It  is  due  to  non-closure  of  the  foetal  umbilical  ring.  The 
plates  that  are  destined  to  become  the  abdominal  wall,  fail  to  close 
in  tightly  around  the  root  of  the  umbilical  cord,  and  thus  an  aper- 
ture is  left  (patent  umbilical  ring)  which  allows  the  abdominal 
organs  to  escape  and  find  their  way  into  the  root  of  the  umbilical 
cord. 

These  hemije  vary  from  the  size  of  a  nut  to  that  of  a  foetal 
head.  They  may  contain  but  a  single  coil  of  intestine  or  a  diver- 
ticulum from  the  ileum  (jMeckel's  diverticulum),  or  they  may  con- 
tain the  entire  length  of  the  intestinal  canal  and  the  liver,  spleen, 
and  heart.  In  the  extreme  cases  the  condition  amounts  practically 
to  complete  eventration.  This  variety  of  hernia  is  frequently  asso- 
ciated with  other  congenital  malformations,  as  extrophy  of  the  bladder, 
spina  bifida,  etc. 


348  ABDOMEN  AND  BACK. 

The  abdominal  contents  which  have  escaped  through  the  patent 
umbilical  ring  are  found  in  the  root  of  the  umbilical  cord,  which 
is  dilated  to  accommodate  them.  The  smaller  hemige  may  be  over- 
looked at  birth,  and  a  loop  of  intestine  contained  within  the  root 
of  the  cord  may  be  included  in  the  ligature  which  is  applied  around 
the  cord,  and  an  miibilical  intestinal  fistula  results. 

The  intestine  can  be  seen  through  the  thin  transparent  layers 
that  form  the  coverings  of  the  hernia.  The  coverings  are,  exter- 
nally, that  portion  of  the  amnion  which  forms  the  envelope  or 
sheath  of  the  umbilical  cord,  and  Avhich  is  continuous  around  the 
base  of  the  hernia  with  the  skin  that  covers  the  abdomen;  inter- 
nally, lining  the  interior  of  the  hernia  and  forming  the  sac  proper 
of  the  hernia,  is  the  peritoneum.  Between  these  two  thin  layers 
are  found  the  umbilical  vessels  and  a  certain  amount  of  Wharton's 
jelly.  x\n  umbilical  cord  with  a  funnel-shaped  root,  and  with  a 
broad  base  corresponding  to  its  attachment  at  the  navel,  should  excite 
suspicion  that  a  congenital  hernia  exists.  The  children  with  large 
hemise  usually  die;  the  smaller  hemige  may  oftentimes  be  remedied 
by  timely  surgical  operation. 

Operation  for  the  cure  of  congenital  hernia  should  be  under- 
taken soon  after  birth.  An  incision  is  made  through  the  skin  close 
to  the  root  of  the  umbilical  cord  and  exposing  the  sac  of  the  hernia- 
peritoneum.  The  umbilical  vessels  are  ligated  and  cut  short.  The 
sac  is  incised  and  the  contents  reduced.  The  sac  is  ligated  and 
resected,  and  the  edges  of  the  ring  approximated  with  several  sutures 
of  fine  kangaroo  tendon.  The  edges  of  the  skin  are  united  with 
several  sutures  of  catgut. 

Infantile  Hernia. — The  umbilical  hernia  of  young  children. 
This  variety  of  hernia  is  of  frequent  occurrence.  It  is  acquired  after 
birth,  and  should  not  be  confounded  with  congenital  hernia. 

After  birth  the  stump  of  the  umbilical  cord  cicatrizes,  and 
the  umbilical  ring  gradually  contracts,  becoming  smaller  and  smaller. 
After  the  lapse  of  several  months  the  ring  has  become  completely 
obliterated,  being  filled  in  with  a  plug  of  dense  connective  tissue, 
and  surrounds  and  grips  the  remains  of  the  umbilical  vessels  very 
closely.  The  sooner  after  birth  an  infantile  hernia  makes  its  appear- 
ance, the  larger  the  ring  will  be  and  the  weaker  the  cicatrix;  hence 
the  larger  the  hernia  is  apt  to  be. 

This  variety  of  hernia  is  more  frequently  seen  in  male  than 
female  children,  and  among  the  poorly  nourished.     It  is  caused  by 


OPERATIONS  FOR  HERNIA,  ETC.  349 

the  straining,  cn'ing,  coughing  that  accompany  gastro-enteritis, 
bronchitis,  phimosis,  etc.,  during  the  first  weeks  and  months  after 
birth,  and  before  the  umbilical  ring  has  had  time  to  become  obliter- 
ated to  a  degree  sufficient  to  offer  adequate  resistance. 

The  opening  corresponds  to  the  umbilical  ring,  is  usually  small, 
oval,  and  transverse  in  direction,  or  it  may  be  round.  The  cover- 
ings consist  of  the  skin,  a  layer  of  connective  tissue  representing 
the  stretched  out  umbilical  cicatrix,  and,  internally,  lining  the 
protrusion,  the  peritoneum  which  forms  the  sac  proper  of  the 
hernia. 

These  hernise  rarely  become  strangulated,  and  in  growing 
children  have  a  natural  tendency  to  spontaneous  cure.  Operation 
is  rarelv,  if  ever,  indicated.  It  suffices  to  relieve  the  cause:  bron- 
chitis, pliimosis,  etc.,  and  to  apply  a  belly-band  with  a  fiat  pad  which 
is  larger  than  the  umbilical  opening,  so  that  it  covers  the  opening 
and  extends  well  beyond  its  margin. 

Umbilical  Hernia  in  Adults. — This  condition  is  more  fre- 
quently seen  in  women,  and  especially  those  who  have  borne  many 
children,  than  in  men,  and  more  in  stout  people  and  those  with 
pendulous  bellies.  These  hernite  vary  in  size ;  some  are  very  large, 
large  as  a  child's  head  or  larger.  As  a  rule  they  are  partly  or 
completely  irreducible.  The  contents,  which  consist  of  intestine 
(commonly  the  transverse  colon)  and  gi'eat  omentum,  are  frequently 
adherent  to  the  interior  of  the  sac,  and  thus  render  the  hernia 
partially  or  completely  irreducible.  At  times  portions  of  the  intes- 
tine or  processes  of  fat  from  the  intestine  or  omentum  work  their 
way  through  the  sac  and  become  intimately  united  with  the  sub- 
cutaneous fat  layer.  At  operation  under  these  conditions  the  con- 
tents may  be  encountered  directly  underneath  the  skin.  The  con- 
tents escape  from  the  abdominal  cavity  through  the  umbilical  ring 
which,  in  some  cases,  is  considerably  enlarged.  The  coverings  of 
this  variety  of  hernia  consist  of  the  skin,  which  may  be  very  thin 
and  presenting  the  umbilicus  oftentimes  flattened  out  and  nearly 
obliterated;  the  subcutaneous  fat  layer;  a  thin  fibrous  layer  corre- 
sponding to  the  stretched-out,  attenuated  umbilical  cicatrix,  and 
the  peritoneum  which  lines  the  interior  of  the  hernia  and  forms 
the  sac  proper.  The  subcutaneous  fat  layer  varies  much  in  thick- 
ness; sometimes  it  is  very  thick  or  it  may  be  very  thin,  especially 
over  the  summit  of  the  hernia;  maybe  so  thin  that  the  sac  of  the 
hernia    is    encountered    almost    directly   under    the    skin.      The   sac 


350  ABDOMEN  AND  BACK. 

may  be  perforated  by  the  intestine  and  by  processes  of  fat  that 
grow  from  the  intestine  and  omentum.  These  structures,  after 
penetrating  the  sac,  become  fused  with  the  fat  in  the  subcutaneous 
layer,  and  may  be  intimately  adherent  to  the  skin.  At  times,  espe- 
cially in  large  hernige  and  in  the  neighborhood  of  the  navel,  the 
coverings  of  the  hernia,  skin,  and  fatty  layers,  are  so  thin  that 
an  incision  made  over  this  part  of  the  hernia  would  come  down 
abruptly  upon,  and  maybe  injure,  the  contents  (gut)  ;  hence  an 
elliptical  incision  corresponding  to  the  base  of  the  hernia  is  used, 
rather  than  one  over  the  summit  of  the  hernia,  for  the  purpose  of 
exposing  the  sac. 


Fig.  156.— Umbilical  Hernia.  The  entire  hernia  mass  has  been  dissected 
free  around  its  base  exposing  the  aponeurosis  of  the  external  oblique  and 
the  edge  of  the  umbilical  ring.  Pedicle  of  the  mass  corresponds  to  the  neck 
of  the  sac  as  it  emerges  through  ring. 

Mayo's  Operation. — An  elliptical  incision  with  the  long  diameter 
transversely,  is  made  into  the  fatty  layer,  some  distance  from  and 
surrounding  the  umbilicus.  This  incision  corresponds  to  the  base 
of  the  hernia  mass.  The  neck  of  the  sac  is  sought  and  reognized, 
and  the  abdominal  aponeurotic  layer,  for  a  distance  of  two  or  three 
inches  beyond  the  neck  of  the  sac,  is  dissected  clean  and  plainly 
exposed  to  view.  The  sharp,  well-defined  aponeurotic  edge  of  the 
opening  through  which  the  hernia  protrudes,  may  be  distinctly  made 
out  with  the  finger. 

The  sac  of  the  hernia  is  incised  in  a  circular  manner  around 
the  neck,   thus   exposing   the   contents.      Intestine   that   is    present 


OPERATIONS  FOR  HERNIA,  ETC. 


351 


and  adherent  within  the  sac  is  carefully  separated  and  returned 
into  the  abdomen.  Omentum  is  ligated  and  divided,  the  ligated 
stump  being  allowed  to  slip  back  into  the  abdomen.  The  sac,  which 
has  already  been  divided  by  the  incision  around  its  neck,  and  the 
omentum,  which  has  been  resected  and  which  is  usually  adherent 
to  the  sac,  may  be  thus  removed  in  one  mass.  The  finger  is  intro- 
duced through  the  mouth  of  the  sac  and  swept  all  around  to  make 
certain  that  there  are  no  adhesions  to  the  margin  of  the  ring. 

An  incision  is  made  through  the  aponeurotic  and  peritoneal 
layers  of  the  ring  extending  for  a  distance  of  one  inch  or  less,. 
transversely,   on   each   side.      The   peritoneal   layer  is   detached  with 


Fig.  157.— Umbilical  Hernia.  The 
"edges  of  the  peritoneum  corresponding 
to  the  stump  of  the  sac  have  been  su- 
tured. Three  mattress  sutures  have  been 
introduced  through  the  upper  and  lower 
aponeurotic    flaps. 


Fig.  158. — Umbilical  Hernia.  Mat- 
tress sutures  have  been  tied.  The  upper 
aponeurotic  flap  overlaps  the  lower. 
The  edge  of  the  upper  flap  is  secured  to- 
the  lower  with  several  additional  su- 
tures. 


the  finger  from  the  under  surface  of  the  upper  of  the  two  aponeu- 
rotic flaps,  which  are  thus  made.  Three  or  four  mattress  sutures- 
of  heavy  silk  or  of  kangaroo  tendon  are  introduced  in  the  aponeu- 
rotic flaps  in  such  a  manner  that,  when  drawn  tight  and  tied,  they 
cause  the  upper  flap  to  overlap  the  lower  one.  These  sutures  pierce 
the  upper  flap  two  to  two  and  one-half  inches  away  from  its  margin, 
but  secure  the  lower  flap  fairly  close  to  its  margin;  the  sutures 
are  left  untied  temporarily.  The  edges  of  the  peritoneum  are 
united  with  a  continuous  suture  of  plain  catgut.  After  the  edges 
of  the  peritoneum  have  been  united,  the  mattress  sutures  are  drawn 
tight  and  tied,  with  the  result  that  they  draw  the  entire  lower 
aponeurotic   flap   upward,    under   the   upper    aponeurotic   flap,    into 


352  ABDOMEN  AND  BACK. 

the  space  previously  made  to  receive  it  between  the  peritoneum 
and  the  upper  aponeurotic  flap.  The  free  edge  of  the  upper  over- 
lapping flap  is  secured  with  several  additional  sutures  of  chromic 
catgTit  to  the  surface  of  the  aponeurosis  which  lies  beneath  it. 

The  incision  in  the  skin  is  closed  in  the  usual  manner. 

Ventral  Hernia. — By  ventral  hernia  is  meant  a  protrusion  of 
the  abdominal  contents  through  some  opening  in  the  abdominal 
wall  other  than  the  natural  orifices,  umbilical,  inguinal,  femoral 
rings,  etc.,  or  a  protrusion  or  bulging  of  the  abdominal  contents 
due  to  jdelding  of  a  cicatrix  or  of  a  portion  of  the  abdominal  wall 
which  has  been  weakened  by  degeneration  of  the  muscle  or  by  loss 
of  resistance  on  the  part  of  the  aponeurosis  (linea  alba),  permitting 
separation  of  the  rectus  muscles,  etc.  The  ventral  hernige  may  be 
described  in  several  groups. 

Abdominal  Herni.?;. — Sometimes  divided  into  anterior  and 
lateral— depending  upon  their  location.  They  present  in  the  mid- 
dle line,  through  openings  in  the  linea  alba,  above  or  below  the 
umbilicus,  or  through  transverse  openings  (foramina  for  the  transit 
of  blood-vessels)  in  the  tendinous  intersections  of  the  sheath  of 
the  rectus,  or,  laterally,  between  the  outer  edge  of  the  rectus  and 
the  oblique  muscles,  or  they  may  appear  in  the  lumbar  region — in 
Petit's  triangle — between  the  twelfth  rib  and  the  crista  ilei.  Her- 
nige in  the  lumbar  region  should  not  be  mistaken  for  cold  abscess. 

These  hernia  often  reach  considerable  size,  and  may  have  a 
fairly  large  orifice.  They  may  become  irreducible  or  strangulated, 
and  may  call  for  surgical  interference.  They  are  treated  along 
the  same  general  lines  as  described  in  the  operation  for  umbilical 
hernia:  exposure  and  incision  of  the  sac  and  reduction  of  the 
contents.  The  sac  is  ligated  and  resected,  and  the  orifice  closed  by 
overlapping  the  edges  of  the  aponeurosis,  usually  in  a  transverse 
direction,  and  securing  them  thus  with  several  sutures  of  kangaroo 
tendon.     Closure  of  skin  incision. 

Epigastric  Hernia. — Occasionally  we  meet  with  small  hernia, 
usually  not  larger  than  a  hazel  nut,  that  protrude  through  little, 
well-defined,  transverse  openings  in  the  tendinous  intersections — 
lineas  transversa- — ^in  the  upper  part  of  the  recti  or  in  the  linea 
alba  above  the  umbilicus.  These  hernige  really  form  a  group  by 
themselves,  and  are  characterized  by  their  small  size  and  location, 
and  the  peculiar  gastric  and  intestinal  symptoms  with  which  they 
are  associated.  They  appear  in  the  upper  part  of  the  abdomen — 
in  the  epigastric  region. 


OPERATIONS  FOR  HERNIA,   ETC.  353 

These  liernite  are  caused  by  the  penetration  of  little  processes 
of  fat  which  grow  from  the  subperitoneal  layer  forward  through 
little  foramina  (for  the  transit  of  blood-vessels)  in  the  linea  alba, 
or  in  the  tendinous  intersections  of  the  sheath  of  the  rectus.  As 
they  grow  they  draw  a  little  process  or  pouch  of  the  peritoneum 
after  them,  and  this  forms  the  hernia  sac.  These  hernige  are  too 
small  to  contain  gut.  They  usually  contain  a  process  of  fat  which 
may  be  attached  to  the  omentum,  colon  or  stomach.  They  may 
be  irreducible,  owing  to  the  fact  that  the  mouth  of  the  sac  is  too 
narrow  or  because  the  contents  of  the  hernia  have  become  adherent 
within  the  sac.  In  this  way  we  may  account  for  the  gastric  and 
intestinal  pam,  and  symptoms  of  digestive  disturbance  which  are  so 
frequently  associated  with  this  condition.  Treatment  of  these  hemige 
consists  of  incision  and  opening  into  the  sac,  and  reduction  of  contents. 
The  little  sac  is  ligated  and  cut  away,  and  the  edges  of  the  orifice 
approximated  in  a  transverse  direction,  or,  better,  overlapped  and 
secured  with  several  sutures  of  kangaroo  tendon. 

Diastase  of  the  Eecti. — Another  not  imcommon  variety  of 
so-called  ventral  hernia  is  that  seen  in  women  who  have  borne 
children,  and  in  individuals  who  have  suffered  from  ascites  or  who 
have  had  large  intra-abdominal  tumors.  There  is  a  bulging  in  the 
middle  line  due  to  stretching  or  weakening  and  yielding  of  the 
linea  alba,  and  a  separation  of  the  edges  of  the  recti.  The  line 
of  separation  may  reach  from  the  ensiform  cartilage  all  the  way 
down  to  the  symphysis,  or  may  involve  only  the  lower  part  of  the 
linea  alba  from  the  umbilicus  downward. 

When  the  patient  makes  the  effort  to  raise  herself  from  the 
recumbent  to  the  upright  position  through  the  contraction  of  the 
recti,  the  edges  of  the  cleft  between  the  muscles  can  be  distinctly 
felt.  AYhen  the  patient  stands  or  strains  there  is  a  bulging  corre- 
sponding to  the  site  of  the  hernia. 

The  coverings  of  this  variety  of  hernia  are  the  peritoneum 
and  transversalis  fascia,  an  aponeurotic  layer  corresponding  to  the 
stretehed-out  linea  alba  and  the  skin.  The  passage  from  the  abdominal 
cavity  into  the  hernia  is  a  wide,  open  space,  and  there  is  no  danger 
of  the  hernia  becoming  strangadated. 

Fortunately  in  most  cases  after  parturition,  relief  from  ascites, 
etc.,  the  walls  of  the  abdomen  are  sufficiently  lax  to  permit  of  the 
edges  of  the  recti  being  approximated  and  held  in  close  apposition 
with  sutures.    In  this  manner  these  herniae  are  cured. 

23 


354  ABDOMEN  AND  BACK. 

An  incision  is  made  in  the  middle  line  and  the  skin  and  fat 
dissected  outward^  on  either  side,  away  from  the  middle  line,  nntil 
the  aponeurosis  is  clearly  exposed.  The  inner  edge  of  either  rectus 
muscle  is  exposed  by  incising  the  aponeurosis  along  the  edge  of 
each  muscle.  The  layers  that  stretch  across  the  space  between  the 
recti  are  the  attenuated  fibrous  layer  that  corresponds  to  the 
stretched  linea  alba,  the  transversalis  fascia,  and  the  peritoneum. 
It  is  not  necessary  to  incise  these  layers;  they  may  be  infolded 
into  the  abdomen  as  the  edges  of  the  recti  are  approximated.  The 
umbilicus  is  excised,  the  opening  which  results  being  closed  with 
several  catgut  sutures.  The  edges  of  the  recti  are  brought  together 
in  the  middle  line  with  a  number  of  mattress  sutures  of  kangaroo 
tendon.  The  edges  of  the  aponeurosis,  corresponding  to  the  ante- 
rior sheath  of  the  rectus,  are  overlapped,  one  over  the  other,  across 
the  middle  line,  and  secured  thus  with  a  sufficient  number  of  mat- 
tress sutures  of  kangaroo  tendon  placed  fairly  close  together.  The 
edge  of  the  overlapping  aponeurotic  layer  is  sutured  to  the  surface 
of  the  overlapped  layer  with  a  continuous  suture  of  chromic  catgut 
in  order  to  fix  it  still  more  securely.  Finally  the  edges  of  the  skin, 
which  is  more  than  abundant,  are  trimmed  away  and  sutured 
together. 

PosT-OPEEATiVE  Ventral  Hernia. — A  common  variety  of 
ventral  hernia  is  that  which  follows  incision  in  the  abdominal  wall, 
wounds,  etc.  Hernia  is  less  likely  to  follow  careful  suturing,  and 
where  healing  by  first  intention  results.  The  condition  is  due  to 
failure  of  the  edges  of  the  aponeurosis  to  unite  securely,  and  to 
weakening  and  yielding  of  the  cicatrix  and  to  degeneration  of  the 
muscle.  In  those  cases  where  the  healing  process  has  been  accom- 
panied by  intra-peritoneal  suppuration  and  drainage  has  been  neces- 
sary, we  find  the  intestine  and  omentum  adherent  to  the  interior  of 
the  sac  (peritoneum)  along  the  line  of  the  cicatrix. 

This  variety  of  hernia  is  seen  in  the  middle  line  and  laterally; 
in  the  usual  sites  of  incision  for  operations  on  the  uterus,  tubes,  etc. ; 
for  gall-stones,  appendicitis,  colostomy. 

These  hernige  are  sometimes  very  large.  The  contents  bulge 
into  the  hernia  through  a  large,  roomy  passage  corresponding  to 
the  location  in  the  fascia,  muscle,  and  aponeurosis,  where  the  parts 
have  failed  to  unite.  There  is  but  slight  danger  of  strangulation. 
The  coverings  consist  of  the  skin,  which  presents  the  cicatrix; 
maybe  or  maybe  not  the  transversalis  fascia,  and  the  peritoneum 
which  lines  the  interior  of  the  protrusion  and  forms  the  sac  of  the 


SURGICAL  ANATOMY  OF  THE  STOMACH.  355 

hernia.     The  contents,  intestine,  omentum,  etc.,  are  usually  adherent 
to  the  sac  (peritoneum)  along  the  line  of  the  cicatrix. 

An  elliptical  incision  which  surrounds  the  cicatrix  is  made,  the 
long  axis  of  the  ellipse  corresponding  to  the  line  of  the  cicatrix. 
The  incision  penetrates  the  skin  down  into  the  fat  layer.  Search 
is  made  around  the  hase  of  the  hernia  for  the  aponeurosis,  which 
should  be  exposed  all  around  for  an  inch  or  more.  The  edges  of 
the  aponeurosis  are  recognized  and  dissected  clean.  Underneath 
tlie  aponeurosis  the  edges  of  the  muscle  are  sought  for  and  exposed. 
The  peritoneal  layer  is  incised,  and  the  abdominal  cavity  is  entered. 
Care  must  be  exercised  when  the  peritoneum  is  incised  and  the 
abdomen  entered  not  to  injure  adherent  gut  and  omentum.  Omen- 
tum, which  is  adherent  to  the  (sac)  peritoneum,  is  ligated  and 
divided.  Adherent  gut  is  carefully  detached  from  the  peritoneum 
surface  along  the  line  of  the  cicatrix.  If  the  gut  is  accidentally 
torn  the  opening  must  be  closed  with  a  Lembert  suture.  After  the 
omentum  has  been  separated  or  ligated  and  divided,  and  adherent 
gut  separated  and  returned  to  the  abdomen,  we  proceed  to  close 
the  abdominal  incision.  The  edges  of  the  peritoneum,  and  includ- 
ing the  transversalis  fascia  in  order  to  secure  a  better  hold,  are 
sutured  together  with  a  continuous  catgut  stitch.  The  edges  of 
the  muscle  are  next  approximated  with  several  chromic  catgut  sutures. 
The  edges  of  the  aponeurosis  should  be  overlapped,  if  possible,  and 
joined  securely  with  a  sufficient  number  of  sutures  of  kangaroo 
tendon  in  a  manner  similar  to  that  employed  for  the  cure  of  diastase 
of  the  recti,  as  described  above.  The  edges  of  the  skin  are  brought 
together  in  the  usual  manner. 

THE    STOMACH. 

The  Surgical  Anatomy  of  the  Stomach. — ^The  stomach  is  a  pear- 
shaped,  pouched  portion  of  the  alimentary  canal  with  a  capacity 
of  from  three  to  four  pints.  It  is  suspended  obliquely  in  the  upper 
part  of  the  abdomen,  upon  the  left  side,  extending  from  the  oesophagus 
to  the  duodenum.  Its  walls  are  thick,  and  consist  of  a  serous,  a 
muscular,  a  submucous  and  a  mucous  membrane  coat. 

The  larger  end  of  the  stomach,  the  cardiac,  is  above  and  toward 
the  left  side;  the  smaller  end,  the  pyloric,  is  below  and  toward  the 
Tight  side. 

The  oesophageal  opening  is  called  the  cardiac,  and  the  open- 
ing into  the  duodenum,  the  pyloric  orifice.  The  dilated  left  end 
of  the  stomach — i.e.,  that  part  to  the  left  of  the  oesophageal  open- 


356  ABDOMEN  AND  BACK. 

ing — is  called  the  fundus ;  the  middle  part,  the  hody ;  and  the  right, 
rather  constricted  portion,  the  pylorus. 

The  stomach  presents  an  upper  or  right  border,  the  lesser 
curvature,  and  a  lower  or  left  border,  the  greater  curvature.  The 
lesser  curvature  is  about  four  inches  long,  and  continuous  with 
the  line  of  the  cesophagus,  almost  perpendicular,  straight  up  and 
down.  The  greater  curvature  is  about  three  times  as  long  as  the 
lesser  curvature.  The  stomach  has  an  anterior  wall  which  is  directed 
forward  and  upward,  and  a. posterior  wall  which  is  directed  back- 
ward and  downward. 

The  adult  stomach,  moderately  distended,  measures  in  its 
longest  diameter  from  ten  to  twelve  inches;  from  the  greater  to 
the  lesser  curvature,  four  to  five  inches;  and  from  the  anterior  to 
the  posterior  wall  about  three  and  one-half  inches.  When  the 
stomach  is  empty  the  first  and  second  diameters  are  diminished 
and  the  third  disappears,  as  the  walls  come  into  contact  -wdth  each 
other.  In  this  condition  the  mucosa  is  thrown  into  numerous  folds 
and  rugffi. 

The  opening  between  the  pylorus  and  the  duodenum  is  indi- 
cated by  a  well-marked  thickening  of  the  wall  of  the  stomach.  It 
is  made  up  of  circular  muscular  fibers,  Avhich  act  as  a  sphincter 
and  which  serve  to  shut  ofl!  the  cavity  of  the  stomach  from  that 
of  the  duodenum. 

The  stomach  is  situated  in  the  left  hypochondriac  and  the 
epigastric  regions;  about  five-sixths  part  of  the  organ  lies  to  the 
left  of  the  middle  line,  the  pyloric  end  lying  to  the  right  of  the 
middle  line.  The  cardiac  orifice  is  located  one  inch  below  the 
diaphragm,  to  the  left  of  the  body  of  the  eleventh  dorsal  vertebra, 
and  at  a  depth  of  11  cm.  from  the  front  wall  of  the  abdomen,  on 
a  line  directly  behind  the  articulation  of  the  seventh  left  costal 
cartilage  with  the  sternum.  The  ]Dyloric  orifice  lies  to  the  right 
and  a  little  below  the  ensiform  cartilage  and  nearer  the  anterior 
wall  of  the  abdomen.  The  direction  of  a  line  drawn  from  the  cardiac 
orifice  to  the  pyloric  orifice  Avould  be  downward  and  to  the  right. 
The  fundus  of  the  stomach  reaches  upward  as  high  as  the  level  of 
the  fifth  costal  cartilage,  and  is  separated  from  the  base  of  the  left 
lung  by  the  diaphragm. 

The  anterior  surface  of  the  stomach,  toward  the  left,  is  in 
relation  with  the  seventh,  eighth,  and  ninth  ribs,  the  diaphragm 
being  interposed;  the  pyloric  end  and  upper  part  of  the  anterior 
surface  of  the  stomach   are  covered  by  the  left  lol^e  of  the  liver. 


SURGICAL  ANATOMY  .OF  THE   STOMACH. 


357 


LESSER 
OMENTUM 


Corresponding  to  tlie  lower  border  of  tlie  stomach,  along  its  great 
curvature  and  attached  to  it  b}^  the  so-called  gastro-colic  ligament,  is 
the  transverse  colon. 

A  triangular  area  of  the  anterior  wall  of  the  stomach — near 
the  left  free  border  of  the  ribs — is  in  direct  relation  with  the 
anterior  abdominal  wall,  and  is  here  accessil)le  for  operation.  The 
base  of  this  triangular  space  is  indicated  npon  the  surface  of  the 
abdomen  by  a  transverse  line,  which  corresponds  to  the  transverse 
colon  and  greater  cnrvatui'e  of  the  stomach,  and  which  is  drawn 
through  the  tip  of  the  tenth  rib  (cos- 
tal cartilage)  of  either  side.  The 
other  lines  of  the  triangle  are,  npon 
the  left,  the  free  border  of  the  ribs, 
and,  upon  the  right  side,  a  line  cor- 
responding to  the  anterior  thin  edge 
of  the  left  lobe  of  the  liver,  which  is 
drawn  from  the  tip  of  the  tenth  right 
costal  cartilage  to  the  tip  of  the 
eighth  left  costal  cartilage. 

Behind  the  stomach  lie  the  pan- 
creas, with  the  splenic  vessels. passing 
along  its  upper  border,  the  commence- 
ment of  the  jejunum,  the  upper  part  of 
the  left  kidney  and  suprarenal  capsule, 
and,  toward  the  left,  the  spleen. 

Behind  the  pyloric  end  of  the 
stomach  are  the  duodenum,  portal 
vein  and  common  bile-duct,  head  of 
the  pancreas  and  first  lumbar  verte- 
bra, crura  of  the  diaphragm,  aorta 
with  the  coeliac  axis,  solar  sympathetic 
plexus,  thoracic  duct,  vena  cava  in- 
ferior, etc. 

The  spleen  lies  to  the  left  of  the 
stomach  and  rather  behind  it.     The  gall-bladder  is  in  relation  with 
the  pyloric  end  of  the  stomach. 

The  stomach  is  entirely  enveloped  by  the  peritoneum,  which 
forms  its  serous  coat;  above,  extending  between  the  transverse 
fissure  of  the  liver  and  the  lesser  curvature  of  the  stomach,  the 
two  layers  of  the  peritoneum  join  to  form  the  lesser  omentum, 
gastro-hepatic   ligament,   between    the    layers    of    which,    toward    its 


rftANSV. 
COLON 


Fig.  159. — Sagittal  Section  to 
Show  the  Arrangement  of  the 
Great  and  Lesser  Omenta,  etc.  *, 
indicates  situation  where  the  lay- 
ers of  the  great  omentum  become 
fused  to  that  portion  of  the  peri- 
toneum which  invests  the  trans- 
verse colon,  thus  joining  the  latter 
to  the  lower  border  of  the  stomach. 


358  ABDOMEN  AND  BACK. 

right  edge,  the  hepatic  artery,  portal  vein,  and  common  bile-duct 
are  located. 

Below,  at  the  greater  curvature,  the  two  layers  of  peritoneum, 
after  enveloping  the  stomach,  again  join  to  form  the  great  omen- 
tum through  which  the  transverse  colon  is  attached  to  the  greater 
curvature  of  the  stomach.  That  portion  of  the  great  omentum 
which  Joins  the  stomach  to  the  transverse  colon  is  called  the  gastro- 
colic ligament.  Toward  the  left,  the  two  layers  of  peritoneum 
which  cover  the  anterior  and  posterior  surfaces  of  the  stomach 
also  join  together  to  form  the  gastro-splenic  omentum,  but  they 
again  separate  so  as  to  invest  the  spleen  and  connect  it  with  the 
fundus  of  the  stomach.  Between  the  layers  of  the  gastro-splenic 
omentum  the  arteria  epiploica  sinistra,  a  large  branch  of  the  splenic, 
and  the  vasa  brevia  pass  to  the  fundus  of  the  stomach. 

The  arteries  which  supply  the  stomach  are  derived  from  the 
coeliac  axis,  and  consist  of  large  branches  which  course  along  the 
lesser  and  greater  curvatures;  these  vessels  give  off  large  branches, 
which  ramify  upon  the  anterior  and  posterior  walls  of  the  stomach, 
coursing  from  the  periphery  toward  the  middle  of  each  surface; 
along  the  lesser  curvature,  the  pjdoric  artery,  a  branch  of  the 
hepatic,  and  the  gastric  artery  anastomose;  along  the  greater 
curvature,  anastomosing  with  each  other,  are  the  gastro-epiploica 
dextra  from  the  hepatic  and  the  gastro-epiploica  sinistra  from  the 
splenic.  The  vasa  brevia,  from  the  splenic,  ramify  upon  the  left 
end,  fundus,  of  the  stomach. 

The  lymphatics  of  the  stomach  form  a  plexus  of  dilated  lymph- 
spaces  in  the  submucous  layer.  From  these  spaces  the  lymphatic 
vessels  run  toward  the  upper  and  lower  borders  and  toward  the 
left  end  of  the  stomach,  where  they  terminate  in  a  number  of 
lymphatic  nodes  that  are  located  between  the  layers  of  the  lesser 
and  greater  omenta  and  the  gastro-splenic  omentum. 

According  to  the  direction  taken  by  the  lymphatics  that  drain 
it,  the  stomach  may  be  divided  into  three  areas:  the  region  adjoin- 
ing the  lesser  curvature,  the  region  adjoining  the  greater  curvature, 
and  that  coiTesponding  to  the  fundus. 

First. — The  l3Tnphatic  vessels  that  drain  that  portion  of  the 
stomach  adjacent  to  the  lesser  curvature  terminate  in  a  chain  of 
nodes  that  are  situated  between  the  folds  of  the  lesser  omentum, 
along  the  course  of  the  gastric  artery,  reaching  from  the  pjdorus 
upward  and  toward  the  left  as  far  as  the  point  where  .the  gastric 
artery  strikes  the  stomach.     Here  they  leave  the  stomach  and  may 


SURGICAL  ANATOMY  OF  THE  STOMACH. 


359 


Fig.  160.— Stomach,  showing  Arteries  that  Supply  it,  its  Lymphatics  and 
Adjacent  Lymph  Nodes.  Corresponding  to  the  lesser  curvature,  the  lym- 
phatics run  in  a  direction  away  from  the  pylorus  to  terminate  in  the  nodes 
along  this  border  of  the  stomach.  Corresponding  to  the  greater  curvature, 
they  run  toward  the  pylorus  to  communicate  with  the  nodes  below  and 
behind  the  pyloric  end  of  the  stomach.  The  lymphatics  of  the  fundus  ter- 
minate in  the  nodes  at  the  hilum  of  the  spleen.  ED,  .epiploica  dextra;  ES 
epiploica  sinistra;  G,  gastric;  GD,  gastro-duodenalis;  H,  hepatic;  P,  pyloric; 
S,  splenic.     Arrows  indicate  direction  of  the  lymph  current. 


360  ABDOMEN  AND  BACK. 

then  be  traced  backward  behind  the  pancreas  to  the  nodes  that  are 
found  adjacent  to  the  coeliac  axis. 

Second. — ^The  lymphatics  that  drain  the  lower  part  of  the  body 
of  the  stomach,  parts  adjacent  to  the  greater  curvature,  run  from 
the  left  downward  and  toward  the  right,  to  terminate  in  a  chain 
of  nodes  spread  along  the  greater  curvature,  and  below  and  behind 
the  pylorus,  along  the  course  of  the  gastro-epiploica  dextra,  whence 
they  may  also  be  traced  to  the  group  of  nodes  about  the  coeliac 
axis. 

Third. — ^The  l3T.iiphatics  that  drain  the  lower  end  of  the  oesoph- 
agus and  the  cardiac  end  of  the  stomach,  fundus,  etc.,  pass  toward 
the  left  and  terminate  in  the  splenic  group  of  nodes  which  are 
situated  near  the  hilum  of  the  spleen,  between  the  folds  of  the 
gastro-splenic  omentum.  These  may  also  be  followed  along  the 
course  of  the  splenic  vessels,  the  upper  border  of  the  pancreas,  to 
their  termination  in  the  nodes  about  the  coeliac  axis. 

OPERATIONS  UPON  THE  STOMACH. 

Plication  of  Gastro-hepatic  Ligaments,  etc.  (Beyea). — Thi.- 
operation  consists  practically  in  "reefing"  the  lesser  omentum,  the- 
ligaments — gastro-hepatic  and  gastro-phrenic — which  suspend  the 
stomach  from  the  liver  and  diaphragm.  It  is  done  for  the  purpose 
of  raising  the,  stomach  up  into  its  normal  position  in  conditions 
of  gastroptosis. 

Incision  is  placed  in  the  middle  line,  four  inches  long,  between 
the  ensiform  process  and  umbilicus.  After  the  abdomen  has 
been  opened  the  liver  is  retracted  upward  and  the  stomach  drawn 
downward.  In  this  way  the  gastro-hepatic  ligaments  (the  fold 
of  peritoneum  that  attaches  the  stomach  to  the  liver)  and  the 
gastro-phrenic  ligament  (a  portion  of  the  same  fold  that  attaches 
the  cardiac  end  of  the  stomach  to  the  diaphragm)  are  exposed  to 
view  and  put  upon  the  stretch  and  their  increased  length  can  be 
readily  appreciated.  Three  rows  of  interrupted  silk  sutures  are 
placed  in  the  ligaments. 

Those  of  the  first  row  are  placed  about  one  inch  or  less  apart 
and  each  takes  a  bite  of  from  one-half  to  one  inch,  the  bites  being 
made  progressively  smaller  as  the  cardiac  end  of  the  stomach  is 
approached.  The  ends  of  all  the  sutures  of  this  first  row  are  seized 
and  held  with  an  artery  forceps.  The  sutures  of  the  second  row 
are  then  introduced  and  take  bites  beyond  those  of  the  first,  and 
thofe  of  the  third  row  l^eyond  those  of  second   (Fig,  162).     Finally 


OPERATIONS  UPON  THE  STO:\L\CH. 


361 


Fig.  161. — Various  Abdominal  Incisions.  B,  mid-rectus  incision;  C,  incision 
for  left  Inguinal  colostomy:  F,  Fenger  incision  for  stomach;  G,  vertical  and 
oblique  incisions  for  gall-bladder,  etc.;  H,  von  Hacker's  incision  for  gastrostomy; 
M,  McBurney  Incision  for  appendicectomy;  S,  incision  for  suprapubic  cystotomy. 
In  middle  line  above  umbilicus  is  linea  alba  incision  for  operations  upon  stomach. 
X  indicates  location  of  anterior  superior  iliac  spine.  Dotted  line  drawn  from 
spine  to  the  umbilicus. 


363 


ABDOMEN  AND  BACK. 


the  sutures  are  all  tied^  first  those  of  the  first  row,  then  those  of 
the  second  row,  and  last  those  of  the  third  row.  The  result  of 
this  operation  is  that  the  stomach,  especially  its  pyloric  portion, 
is  raised  upward  toward  the  liver  and  diaphragm  without  inter- 
fering with  the  mobility  of  the  organ  which  is  essential  to  its 
properly  performing  its  functions. 


Fig.  162. — Plication  of  Gastro-hepatic  Ligament  (Beyea).  1,  2,  and  3  indicate 
a  single  stitch  of  each  of  the  three  rows  that  are  placed  in  the  gastro-hepatic 
ligament  as  represented  by  the  dotted  lines. 


The  sutures  are  of  the  mattress  variet}'',  and  are  introduced 
with  a  small,  curved,  round-pointed  needle. 

Gastroplication. — The  folding  in,  or  "reefing,"  of  a  portion  of 
the  wall  of  the  stomach  in  order  to  diminish  the  size  of  the  organ. 
This  operation  was  first  performed  by  Bircher,  and  is  applicable  to 
cases  of  dilatation  without  stenosis  of  the  pyloric  orifice. 

The  abdominal  incision,  five  to  six  inches  in  length,  may  be 
placed   a   finger's   breadth   distant   from   and   parallel  with   the   left 


OPERATIONS  UPOX  THE  STOMACH. 


363 


free  border  of  the  ribs,  commencing  above  near  the  tip  of  the 
ensiform  process,  or  it  may  be  located  in  the  linea  alba,  reaching 
from  a  point  one  inch  below  the  tip  of  the  ensiform  process  down- 
ward as  far  as  the  nmbilicus.  Through  either  of  these  incisions  the 
stomach  may  be  brought  out  upon  the  abdominal  wall. 

According  to  Bircher,  the  anterior  wall  of  the  stomach  is 
folded  upon  itself  so  that  the  greater  curvature  may  be  brought 
up  close  to  the  lesser  curvature  and  fixed  in  this  position  with  a 
row  of  interrupted  silk  sutures;  these  should  take  a  good,  broad 
bite  in  the  wall  of  the  stomach,  including  its  serous  and  muscular 
coats.     Care  should  be  exercised  that  the  sutures  do  not  penetrate 


Fig.  163. — Cross  Section  of  the 
Stomach  After  Gastroplieation  ac- 
cording to   the  Method   of  Bircher. 


Fig.  164. — Cross  Section  of 
Stomach  After  GastropUcation; 
the  Turned-Up  Portion  Fixed  by 
Four  Rows  of  Sutures.     (Weir.) 


through  the  entire  thickness   of  the  wall   of  the   stomach.     Twelve 
to  fourteen  sutures  are  usually  required. 

According  to  Weir,  the  fixation  may  be  made  with  three  or 
four  separate  tiers  of  sutures,  one  superimposed  upon  the  other. 
After  the  stomach  has  been  brought  out  through  the  abdominal 
incision,  its  anterior  wall,  corresponding  to  the  long  diameter  of 
the  organ,  is  inverted,  and  the  edges  of  the  furrow  thus  made 
in  the  wall  of  the  stomach  united  with  a  row  of  continuous  or 
interrupted  silk  sutures.  A  second  row  of  sutures  is  then  intro- 
duced parallel  with  and  about  one  inch  distant  from  the  first.  A 
third  and  finally  a  fourth  row  may  be  introduced,  the  last  row 
joining  the  greater  curvature  to  the  upper  part  of  the  anterior 
wall  of  the  stomach  near  the  lesser  curvature.  In  this  way  six 
or   eiofht  inches   of  the   stomach   wall   mav  be   reefed    in    and  the 


364  ABDOMEN  AND  BACK. 

organ  materially  reduced  in  size.  No  doubt  the  folding  of  the 
stomach  wall  is  made  more  secure  when  several  rows  of  sutures  are 
used. 

Infolding  of  the  Wall  of  the  Stomach  for  Ulcer. — This  plan  was 
suggested  by  Mitchell  and  answers  well,  provided  the  ulcerated 
area  is  limited  and  accessible,  especially  if  the  anterior  wall  is  the 
portion  involved.  The  stomach  is  exposed  through  an  incision  in 
the  middle  line  commencing  near  the  tip  of  the  ensiform  process  and 
carried  downward  toward  the  umbilicus.  The  ulcerated  portion  of 
the  stomach  wall  is  infolded  or  inverted  into  the  lumen  of  the 
organ  and  fixed  thus  with  two  rows  of  non-penetrating,  Lembert 
sutures  of  silk.  If  the  posterior  wall  of  the  stomach  is  the  portion 
affected  the  operator  may  attempt  to  gain  access  to  this  part  of 
the  organ  through  an  opening  which  is  made  in  the  gastro-colic 
ligament,  or,  better,  in  the  transverse  mesocolon. 

The  beneficial  result  of  the  operation  is  due  to  the  fact  that 
the  diseased  portion  is  placed  at  rest — free  from  peristalsis,  etc. — 
and  it  gradually  atrophies. 

It  might  be  advisable  to  perform  a  gastro-jejunostomy  in  addi- 
tion because  in  some  of  these  cases  the  pyloric  orifice  will  be  found 
to  be  more  or  less  stenosed.  Even  if  no  stenosis  of  the  pyloric 
orifice  is  present  the  gastro-jejunostomy  will  be  beneficial  in  that 
it  permits  easy  and  quick  evacuation  of  the  stomach. 

Gastrotomy.— This  operation  consists  in  making  an  incision  into 
the  stomach  for  the  purpose  of  extracting  a  foreign  body  lodged  in 
the  stomach  or  impacted  low  down  in  the  oesophagus;  for  explora- 
tion of  the  interior  of  the  stomach,  ulcer,  hemorrhage,  etc.,  and  to 
treat  strictures  in  the  lower  part  of  the  oesophagus. 

Immediately  preceding  any  operation  upon  the  stomach  the 
organ  should  be  emptied  and  irrigated,  if  the  conditions  permit, 
with  the  stomach  tube.  This  is  best  done  just  before  the  patient 
is  ansesthetized.  It  is  desirable  that  the  stomach  be  empty  when 
it  is  opened  during  the  course  of  the  operation. 

The  incision  may  be  made  in  the  middle  line  through  the  linea 
alba,  three  to  five  inches  long,  commencing  above  about  one  inch 
below  the  ensiform  process,  and  extending  downward  toward  the 
umbilicus;  or  an  incision  may  be  made  just  to  the  left  of  the 
linea  alba,  passing  through  the  inner  margin  of  the  left  rectus 
muscle;  or  the  Fenger  incision,  parallel  with  the  free  border  of 
the  left   ribs,   may   be   employed.      This    last   incision    (Fenger)    is 


OPERATIONS  UPON  THE  STOMACH.  365 

probably  tlio  best  if  the  ultimate  object  is  to  reach  the  oesophagus 
(see  Fig.  IGl). 

Having  carried  the  incision  clown  to  the  parietal  layer  of  the 
peritoneum,  this  is  picked  up  with  two  toothed  forceps  and  a  small 
incision  made  between  them  with  the  knife;  through  this  incision 
the  finger  is  introduced,  and  upon  tlie  finger,  with  a  blunt-pointed 
scissors,  the  opening  in  the  peritoneum  is  enlarged  so  as  to  corre- 
spond in  length  with  the  incision  in  the  abdominal  wall.  Two 
fingers  are  then  introduced  'into  the  abdomen  and  the  stomach 
searched  for.  If  there  is  a  foreign  body  in  the  stomach,  this  may 
oftentimes  be  felt  and  serves  as  a  guide  to  the  stomach.  The  thin 
anterior  edge  of  the  left  lobe  of  the  liver  may  be  always  readily 
recognized,  and  this  is  a  good  guide  to  the  stomach,  as  the  stomach 
lies  directly  underneath  this  organ,  being  partly  covered  by  it; 
that  part  of  the  anterior  surface  of  the  stomach  which  is  not  cov- 
ered by  the  liver  is  accessible  for  operation ;  it  is  seized  Avith  two 
fingers  and  drawn  out  of  the  abdominal  incision.  If  the  stomach 
is  diminished  in  size  there  may  be  some  difficulty  in  drawing  it  out 
through  the  incision  upon  the  abdomen. 

One  should  not  mistake  the  transverse  colon  for  the  stomach. 
The  transverse  colon  lies  below  and  close  to  the  greater  curvature, 
being  connected  with  the  greater  curvature  by  the  great  omentum 
(gastro-colic  ligament)  ;  the  great  onientum  is  suspended  free, 
apron-like,  from  the  transverse  colon,  and  when  this  part  of  the 
intestine  is  drawn  out  upon  the  abdomen  the  great  omentum  is 
drawn  out  with  it;  the  colon  can  be  further  identified  by  its  saccu- 
lation, by  the  title  fatty  appendices  attached  to  it,  and  by  the 
striae  which  run  along  its  length.  The  wall  of  the  stomach  is 
smooth,  and  the  blood-vessels  ramifying  upon  its  surface  have  a 
characteristic  course,  converging  from  the  periphery  toward  the 
center;  the  gastro-epiploica  dextra  and  sinistra  run  along  the  greater 
curvature  from  either  end  of  the  stomach,  anastomosing  with  each 
other. 

The  stomach  may  be  examined  by  inspection  and  palpation 
before  it  is  opened.  The  posterior  wall  of  the  stomach  may  be 
palpated  through  an  opening  torn  in  the  gastro-colic  ligament.  If 
the  stomach  has  not  been  previously  emptied,  stricture  of  the 
CBSophagus,  etc.,  the  attempt  should  now  be  made  by  the  operator 
to  express  the  contents  onward  into  the  duodenum  before  it  is 
opened. 

A  portion  of  the  stomach  wall  is  drawn  out  through  the  abdomi- 


366  ABDOMEN  AND  BACK. 

nal  incision  and  after  gauze  pads  have  been  properly  arranged  to 
protect  the  peritoneal  cavity  the  stomach  is  incised.  When  the 
incision  is  made  care  should  be  taken  to  prevent  any  stomach  con- 
tents from  entering  or  soiling  the  peritoneal  cavity.  If  there  is 
any  fluid  present  in  the  stomach  when  it  is  opened  this  should 
be  swabbed  out  or  removed  with  a  siphon.  The  stomach  is  best 
incised  in  its  long  diameter  and  the  incision  may  vary  from  one 
to  three  inches.  Bleeding  vessels  may  be  secured  with  artery  forceps. 
Venous  hemorrhage  stops  after  the  artery  forceps  have  been  applied 
for  a  short  time,  but  spurting  arterial  branches  should  be  clamped 
and  tied  with  fine  catgut. 

After  the  removal  of  the  foreign  body  or  examination  of  the 
interior  of  the  stomach  or  treatment  of  ulcer,  etc.,  the  opening  in 
the  stomach  may  be  closed. 

The  closure  of  the  incision  in  the  stomach  is  best  effected  with 
a  continuous  Lembert  suture  of  fine  silk,  which  is  applied  with  a 
fine,  curved,  surgeon's  needle.  This  suture  includes  the  serous  and 
muscular  coats  and  takes  a  good  bite,  each  loop  being  drawn  fairly 
tight.  This  line  of  suture  may  be  reinforced  by  a  second  similar 
row  of  Lembert  sutures  which  bury  the  first  row. 

The  incision  in  the  abdomen  is  closed  first  by  a  continuous  cat- 
gut stitch  which  approximates  the  edges  of  the  parietal  peritoneum 
and  transversalis  fascia,  and  then  a  sufficient  number  of  interrupted 
silkworm-gut  sutures — each  including  the  skin,  aponeurosis,  and 
muscle — are  introduced  or  the  incision  may  be  closed  layer  by  layer. 

For  Bleeding  Ulcer. — Operation  is  indicated  in  this  condition 
when  medical  treatment,  rest,  etc.,  fail  to  control  it  or  if  the  hem- 
orrhage recurs  and  is  profuse.  Owing  to  the  risk  of  increasing  the 
hemorrhage  the  stomach  should  not  be  washed  out  before  operating. 
Loss  of  body  heat  must  be  prevented  as  much  as  possible  during  the 
operation.  When  the  stomach  is  exposed  it  should  be  emptied  by 
expressing  the  contents  onward  into  the  duodenum.  Before  open- 
ing the  stomach  its  surface  should  be  carefully  examined  by  inspec- 
tion and  palpation  in  an  effort  to  locate  the  ulcer;  a  puckering 
of  the  surface,  thickening  of  the  wall,  or  difference  in  color  may 
indicate  its  site.  If  imable  to  obtain  a  clue  to  the  location  of  the 
ulcer  by  these  means,  then  the  stomach  must  be  incised  and  its 
inner  surface  systematically  explored,  first  the  anterior  wall  and 
then  the  posterior,  and  finally  the  cardiac  and  pyloric  ends.  This 
examination  may  be  made  with  the  naked  eye,  bringing  different 
areas   of  the   stomach  wall  into   the   incision,  one  after  the   other, 


OPERATIONS  UPON  THE  STOMACH. 


367 


r0w 


Fig.  165.— Posterior  Wall  of  Stomach  Pushed  out  through  Incision  in  Anterior 
Wall  by  Fingers  Passed  into  Space  behind  Stomach  through  Opening  in  Gastro- 
colic Ligament.     Clamp  applied  to  bleeding  point. 


368  ABDOMEN  AND  BACK. 

or  assisted  by  the  introduction  of  a  speculum  and  the  use  of  a 
reflector.  The  posterior  wall  of  the  stomach  may  be  brought  into 
view  by  introducing  one  or  two  fingers  through  a  rent  in  the  gastro- 
colic ligament  so  as  to  reach  the  posterior  wall  and  invaginate  it, 
pushing  it  forward  into  the  incision  in  the  anterior  wall.  The 
first  part  of  the  duodenum  may  also  be  invaginated  and  examined 
in  the  same  manner.  If  no  ulcer  is  found  and  the  hemorrhage  is 
capillary  in  character  or  comes  from  small,  indiscoverable  ulcers, 
then  a  gastro-jejunostomy  should  be  done. 

If  an  ulcer  can  be  located  it  should  be  excised  if  possible.  The 
edges  of  the  wound  which  is  left  after  the  ulcer  has  been  excised 
are  brought  together  with  catgut  sutures,  one  or  two  layers  being 
used;  if  the  condition  necessitated  cutting  through  the  entire  thick- 
ness of  the  stomach  wall,  then  the  edges  of  the  peritoneal,  serous  coat 
must  be  united  separately  with  a  Lembert  suture  of  silk.  Bleeding 
points  are  clamped  and  ligated. 

If  the  ulcer  involves  the  posterior  wall  it  may  be  excised  from 
within,  working  through  an  incision  in  the  anterior  wall,  the  edges 
of  the  wound  being  brought  together  afterward  with  a  continuous 
catgut  suture.  If  the  entire  thickness  of  the  posterior  wall  of  the 
stomach  has  been  cut  through,  necessitating  the  application  of 
outside  Lembert  sutures,  these  can  be  applied  through  an  opening 
torn  in  the  gastro-colic  ligament,  or,  probably  better,  through  a  rent 
made  in  the  transverse  mesocolon.  Adhesions  between  the  posterior 
wall  of  the  stomach  and  neighboring  organs,  especially  the  pancreas, 
may  add  considerable  difficulty  to  the  proper  'execution  of  this 
plan  of  treatment. 

Should  the  ulcer  involve  a  part  of  the  stomach  wall  which 
is  inaccessible  for  excision,  cardiac  end,  or  should  excision  appear 
inadvisable,  then  the  effort  may  be  made  to  control  the  hemorrhage 
with  the  Paquelin  cautery,  or,  if  one  or  more  individual  bleeding 
points  are  discovered,  an  attempt  may  be  made  to  clamp  and  ligate 
them.  Owing  to  the  friability  of  the  tissues,  these  ligatures  may 
cut  through  and  increase  the  hemorrhage.  Finally,  if  the  hemorrhage 
cannot  be  controlled  by  any  of  the  measures  mentioned,  then,  without 
further  delay,  a  gastro-jejunostomy  should  be  performed. 

If  the  ulcer  involves  the  pylorus,  a  pyloroplasty  according  to 
the  method  of  Finney  may  be  done,  excising  the  diseased  area  at 
the  same  time,  or  a  typical  pylorectomy  may  be  performed  if  time 
and  the  patient's  condition  permit;  or  instead  of  either  of  these 
radical  measures  and  without  further  regard  as  to  the  exact  source 


OPERATIONS  UPON  THE  STOMACH.  369 

of  the  bleeding  or  condition  of  the  pylorus,  a  gastro-Jejunostomy 
may  be  perfonned.  Time  is  an  important  consideration  in  opera- 
tions for  the  control  of  hemorrhage,  and  the  patient's  condition 
may  preclude  prolonged  or  complicated  operative  procedures. 

For  Treatment  of  Stricture  of  the  QEsophagus. — An  ab- 
dominal incision  parallel  with  the  left  free  border  of  ribs,  accord- 
ing to  Fenger,  is  the  most  satisfactory.  After  tlie  stomach  has 
been  incised,  as  described  in  the  preceding  paragraphs,  the  finger 
is  introduced  through  the  opening  in  the  stomach  and  into  the 
oesophageal  orifice;  at  times  it  is  necessary  to  make  a  little  steady 
pressure  with  the  finger  before  this  opening  yields  so  as  to  allow 
the  finger  to  enter.  Conical  rubber  bougies  of  increasing  calibre 
are  then  introduced,  one  after  another,  into  the  cesophagus  and 
up  beyond  the  site  of  the  stricture.  If  the  stricture  is  dense  and 
unyielding,  the  operator  may,  according  to  the  method  of  Abbe, 
pass  a  thin  bougie,  carrying  a  strand  of  braided  silk,  up  into  the 
oesophagus,  through  and  beyond(  the  stricture,  so  tbat  the  end 
carrying  the  silk  cord  may  be  felt  in  the  pharynx.  The  silk  cord 
is  seized  either  in  the  back  of  the  pharynx,  through  the  mouth, 
or  else  through  an  incision  which  is  made  for  that  purpose  in  the 
side  of  the  neck  and  upper  part  of  the  oesophagTis ;  the  bougie  is 
then  withdrawn,  leaving  the  silk  thread  behind  it  in  the  oesophagus. 
A  conical  bougie  is  now  again  introduced  into  the  oesophagus  from 
below  through  the  opening  in  the  stomach;  this  bougie  should  be 
large  enough  to  become  tightly  engaged  in  the  stricture;  the  ends 
of  the  silk  string  are  then  seized  and  it  is  drawn  back  and  forth 
several  times;  it  will  then  be  observed  that  the  bougie  can  be 
passed  farther  and  farther  into  the  stricture;  bougies  of  increasing 
calibre  are  used  in  this  manner  until  the  stricture  is  sufficiently 
relieved.  The  incision  of  the  stricture  which  is  made  by  the  fric- 
tion of  the  silk  string  is  accomplished  with  but  little  hemorrhage. 
The  bougie  and  string  are  finally  withdrawn  and  a  rubber  tube 
Avhich  is  pennitted  to  remain  is  passed  into  the  oesophagais.  its  end 
projecting  through  the  opening  in  the  stomach  and  out  of  the  ab- 
dominal incision.  Besides  this  tube  which  reaches  up  into  the 
oesophagus,  a  second  one  may  be  introduced  into  the  stomach  and 
left  there  for  the  purpose  of  feeding. 

In  the  abdominal  incision  the  edges  of  the  parietal  peritoneum 
are  fixed  to  the  corresponding  margins  of  the  skin  with  several 
.catgut  sutures  and  the  edges  of  the  opening  in  the  stomach  then 

24 


370  ABDOMEN  AND  BACK. 

united  to  the  edges  of  the  abdominal  incision  with  a  sufficient 
number  of  interrupted  silk  sutures,  the  ends  of  the  sutures  being 
left  long  in  order  to  facilitate  their  removal  later.  The  abdominal 
incision,  except  for  that  portion  to  which  the  stomach  has  been 
sutured,    should   be    closed    with    interrupted    silkworm-gut    sutures. 


Fig.  166.— Pyloroplasty.     Horizontal  incision  into  the  pylorus. 

This  is  practically  a  gastrostomy,  and  through  the  opening  in 
the  stomach  the  effort  to  relieve  the  stricture  of  the  oesophagus 
may  be  repeated  if  necessary  after  an  interval  of  several  days.  The 
gastric  fistula  that  remains  closes  spontaneously  or  may  be  closed 
by  a  secondary  plastic  operation. 


Fig.  167.— Pyloroplasty.     Horizontal  converted  into  a  vertical  incision 
and  sutures  placed. 

Pyloroplasty. — For  the  relief  of  cicatricial  stricture  of  the  pylorus 
causing  obstruction  to  the  emptying  of  the  stomach. 

Heinecke-Mikulicz  Method. — The  results  obtained  from  this 
operation  are  not  entirely  satisfactory.  In  many  cases  the  symp- 
toms of  pyloric  obstruction  return  after  a  brief  period  of  relief. 
The  operation  should  not  be  performed  in  cases  where  a  condition 
of  active  ulceration  exists.  Under  such  conditions  a  pylorectomy 
is  the  preferable  operation. 


Fig.  168.— Pyloroplasty    (Finiici/).      Tractor    stitches    have    been    placed    and    the 
posterior  line  of  suture  joining  duodenum  to  stomach  has  been  inserted. 


Fig.  169.— Pyloroplasty    (Finney).      The    anterior    row    of    mattress    sutures    has 
been  introduced,  but  not  tied. 


373  ABDOMEN  AND  BACK. 

The  stomach  is  exposed  through  an  incision  in  the  middle  line 
and  its  pyloric  end  drawn  out  through  the  incision.  Pads  are  then 
properly  placed  to  protect  the  peritoneal  cavity  during  the  rest  of 
the  operation. 

The  pylorus  is  incised  in  its  long  axis,  a  clean  cut  being  made 
through  all  its  coats;  this  incision  should  be  liberal,  from  4  to  6 
cm.  long,  reaching  crosswise  from  the  stomach  through  the  pylorus 
into  the  duodenum.  The  edges  of  the  incision  are  drawn  widely 
apart  by  tenacula  hooked  in  the  middle  of  each  edge,  and  in  this 
way  the  transverse  incision  becomes  converted  into  a  vertical  one. 
In  this  position,  the  opening  is  closed  by  a  row  of  interrupted  Lem- 
bert  sutures  which  take  a  good,  deep,  and  broad  bite,  these  being 
reinforced  and  buried  by  a  second  row  of  Lembert  sutures,  which 
may  be  continuous.  All  the  sutures  are  of  silk.  Care  should  be 
taken  to  close  the  opening  accurately,  especially  in  the  middle  of 
each  edge, — ^the  points  which  correspond  to  the  extremities  of  the 
original  incision.  The  result  is  a  marked  widening  of  the  pyloric 
orifice.  The  incision  in  the  abdomen  is  closed  according  to  any  of 
the  usual  methods. 

Finney  Method. — The  result  of  this  operation  is  a  gastro- 
duodenostomy.  For  benign  stricture  of  the  pylorus,  for  chronic 
ulcer,  etc. 

The  incision,  longitudinal,  is  placed  to  the  right  of  the  median 
line,  penetrating  between  the  fibers  of  the  rectus.  It  commences 
near  the  ensiform  cartilage  and  is  carried  downward  for  a  distance 
of  from  six  to  eight  inches. 

After  the  abdomen  has  been,  opened  the  pylorus  is  sought  for 
and  adhesions  that  bind  it  to  the  adjacent  organs  separated  or 
divided.  The  pyloric  end  of  the  stomach  and  the  first  part  of  the 
duodenum  should  be  freed  as  completely  as  possible.  Upon  the 
thoroughness  with  which  this  step  of  the  operation  is  accomplished 
will  depend  in  a  large  measure  the  success  of  the  operation  and 
the  facility  and  rapidity  with  which  the  subsequent  steps  are 
executed.  At  times  the  pylorus  and  duodenum  will  be  found  to 
be  apparently  hopelessly  adherent,  but  after  a  little  patient  effort 
with  blunt  dissection  and  occasional  careful,  judicious  use  of  the 
scalpel  it  may  be  freed  with  comparative  ease.  The  method  of 
mobilizing  the  duodenum  described  by  Kocher  may  be  used  with 
excellent  effect.  See  mobilization  of  the  duodenum,  "G-astro-duo- 
denostomy,"  page  438. 

After  the  duodenum  and  pylorus  have  been  mobilized,  a  silk 


Fig.  170.— Pyloroplasty  {FiiuiCi/).  Anterior  mattress  sutures  retracted  upward 
and  downward  and  horseshoe-shaped  incision  made,  one  arm  cutting  into  duo- 
denum and  the  other  Into  stomach. 


\^^ 

D     ^ 

IP 

m 

^i^~ 

^pF 

A 

Fig.  171.— Pyloroplasty  (Fuineii).  Posterior  raw  edges  of  incisions  in  duo- 
denum and  stomach  have  been  united  with  a  continuous  suture.  It  remains  now, 
to  complete  the  operation,  to  release  the  anterior  mattress  sutures,  draw  them 
tight,  and  tie. 


374  ABDOIIEN  AND  BACK. 

suture  which  is  to  serve  as  a  tractor  is  placed  in  the  upper  part  of 
the  pylorus,  and  with  this  the  pylorus  is  drawn  upward.  A  second 
tractor  suture  is  inserted  in  the  anterior  wall  of  the  stomach,  near 
the  greater  curvature,  and  a  third  in  the  anterior  wall  of  the  duo- 
denum. The  second  and  third  tractors  should  he  placed  at  points 
equidistant — about  12  cm. — from  the  tractor  that  has  been  applied 
to  the  pylorus.  These  sutures  are  temporary  and  should  be  of  silk 
and  take  a  good,  broad  bite  in  the  walls  of  the  organs,  but  should 
not  penetrate  through  their  entire  thiclaiess.  The  second  and 
third  serve  to  indicate  the  lower  ends  of  the  incisions  that  are  to 
be  made  in  the  stomach  and  duodenum  respectively,  and  should  be 
placed  as  low  as  possible  in  order  that  the  new  pyloric  opening 
may  be  sufficiently  large.  While  the  upper,  pyloric,  tractor  is  drawn 
upward,  the  lower,  gastric  and  duodenal,  tractors  are  pulled  down- 
ward so  as  to  make  the  stomach  and  duodenal  surfaces  taut  and 
bring  them  into  apposition  in  order  to  facilitate  the  placing  of  the 
line  of  suture  that  is  to  join  them  together.  The  first  part  of  the 
duodenum  and  the  corresponding  part  of  the  stomach,  along  its 
greater  curvature,  are  united  from  above  downward  as  far  as  the 
lower,  gastric  and  duodenal,  tractors  with  a  continuous  non-pene- 
trating Lembert  suture  of  silk.  After  this  row  of  sutures  has  been 
applied,  a  second  roAv  of  sutures,  mattress  variety,  is  introduced 
along  a  line  anterior  to  the  first  row  of  sutures.  Ample  space 
should  be  left  between  the  first,  posterior,  row  of  sutures  and  this 
second,  anterior,  row  of  mattress  sutures  in  order  to  permit  of 
making  the  incisions  in  the  stomach  and  duodenum  between  them. 
The  anterior  mattress  sutures  should  take  a  good  bite  in  the  serous 
and  muscular  coats  of  the  stomach  and  duodenum,  but  they  should 
not  penetrate  the  entire  thickness  of  the  walls  of  the  organs. 

The  anterior  row  of  mattress  sutures  are  not  tied  but  are  left 
long  and  loose,  their  ends  caught  with  artery  forceps  and  their 
loops  drawn  upward  and  downward  with  blunt  hooks.  While  the 
mattress  sutures  are  thus  held  out  of  the  way  the  incision  into  the 
stomach  and  duodenum  is  made.  The  incision  is  horseshoe-shaped. 
The  gastric  arm  of  the  incision  is  made  in  the  stomach  wall  com- 
mencing just  above  the  lowest  point  of  the  line  of  suture;  it  is 
carried  up  to  and  through  the  pylorus  and  around  into  the  attached 
portion  of  the  duodenum  to  a  point  opposite  where  it  commenced 
in  the  stomach.  Hemorrhage  from  the  edges  of  the  incisions  in  the 
stomach  and  duodenum  is  then  controlled;  for  this  purpose  clamps 
may  be   applied   temporarily;   but,   as   a   rule,   it  is   unnecessary   to 


OPERATIONS  UPON  THE  STOjVIACH.  375 

employ  any  ligatures  because  the  l)leeding  usually  ceases  when  the 
edges  of  the  incisions  are  sutured  together.  It  is  desirable  to  resect 
as  much  as  possible  of  the  cicatricial  tissue  present  upon  either  side 
of  the  incision  in  order  to  limit  subsequent  contraction.  The  re- 
dundant edges  of  the  mucous  meml)rane  may  be  trimmed  away  so 
as  to  make  the  opening  of  the  new  pylorus  as  large  and  free  as 
possible. 

The  contiguous  edges  of  the  horseshoe  opening  for  the  pos- 
terior part  of  their  extent  are  united  to  each  other  with  a  con- 
tinuous, through-and-through  suture  of  catgL^t.  The  anterior  row 
of  mattress  sutures  are  then  drawn  tight  and  tied  and  the  operation 
is  thus  complete.  Several  additional  Lembert  sutures  of  silk  may 
be  placed  in  front  of  the  line  of  mattress  sutures,  burying  them, 
so  as  to  secure  the  parts  still  more  firmly ;  this  is,  however,  probably 
unnecessary. 

The  incision  in  the  abdomen  is  closed  either  layer  by  layer  or 
else  with  a  sufficient  number  of  interrupted  sutures  of  silk  that 
penetrate  all  the  layers  of  the  abdomen,  special  care  being  taken 
to  include  the  peritoneum  in  each  stitch. 

With  Clamps. — According  to  the  method  of  Gould,  the  Finney 
operation  may  be  done  in  a  manner  analogous  to  that  described  in 
"Gastro-jejunostomj^,  Clamp  Method."  A  fold  of  the  wall  of  the 
stomach  and  a  fold  of  the  wall  of  the  duodenum  are  secured  with 
the  holding  forceps,  the  blades  sheathed  with  rubber  tubing.  The 
folds  grasped  with  the  forceps  are  about  four  inches  in  length. 
The  blades  of  the  forceps  are  placed  side  by  side,  and  the  folds  of 
stomach  and  duodenum  united  with  a  non-penetrating  continuous 
suture  of  silk  in  a  manner  similar  to  that  described  in  gastro- 
jejunostomy. The  needle  still  carrying  the  thread  is  then  laid 
aside  until  needed  later  to  complete  the  operation.  The  folds  of 
stomach  and  duodenum  are  incised  and  the  corresponding  edges 
of  the  openings  joined  to  each  other  with  a  continuous,  through- 
and-through  suture  of  chromic  catgut.  The  clamps  are  removed 
and  the  needle  carrying  the  silk  thread  with  which  the  stomach 
and  duodenum  were  originally  joined  is  again  taken  in  hand  and 
the  operation  completed  by  applying  the  anterior  half  of  the  non- 
penetrating stitch  which  joins  the  stomach  and  duodenum  together. 

Gastrostomy. — The  formation  of  a  permanent  gastric  fistula  for 
the  purpose  of  feeding  in  cases  of  simple  or  malignant  stricture  of 
the  oesophagus.  The  fistula  should  permit  the  introduction  of  nutri- 
ment and  at  the  same  time  prevent  the  escape  of  stomach  contents. 


376  ABDOMEN  AND  BACK. 

Method  of  Ssabanajew  and  Pkanck. — A  very  satisfactory 
operation.  The  incision  is  placed  parallel  with  the  left  free  border  of 
the  ribs  and  should  be  not  more  than  two  inches  long,  commencing 
above  to  the  side  of  ensiform  process.  The  upper  end  of  the  incision 
is  opposite  the  tip  of  the  cartilage  of  the  eighth  rib.  The  incision  is 
continued  down  through  the  muscles  and  parietal  peritoneum.  The 
margins  of  the  peritoneum  and  fascia  transversalis  are  fixed  to  the 
edges  of  the  muscles  in  the  abdominal  incision  with  one  or  two  catgut 
stitches  on  either  side,  near  the  middle.  The  anterior  wall  of  the 
stomach,  near  the  fundus,  is  seized  with  two  fingers,  and  drawn  out 
of  the  wound  in  a  cone-shaped  process  one  and  one-half  to  two  inches 
long  and  a  silk  sling  suture  passed  through  its  apex  to  serve  as  a 
tractor.  The  base  of  this  process  of  the  stomach  wall  is  fixed  all 
around  to  the  edges  of  the  incision  in  the  abdomen  with  a  continuous 
chromic  catgut  suture.  This  suture  includes  the  serous  and  muscular 
coats  of  the  stomach  and  the  edges  of  the  parietal  peritoneum  and 
transversalis  fascia  and  deep  muscular  layer  in  the  abdominal  incision. 
They  do  not  pass  through  the  skin  nor  should  they  pass  through  the 
entire  thickness  of  the  stomach  wall.  After  this  step  of  the  operation 
has  been  completed  a  second  short  incision  about  three-fourths  inch 
long  is  made  through  the  integument,  one  and  one-half  inches  above 
and  parallel  with  the  first  incision  and  well  above  the  free  border  of 
the  ribs.  The  bridge  of  integument  that  intervenes  between  this  and 
the  first  incision  is  raised  bluntly  with  the  handle  of  the  knife  and, 
using  the  silk  sling  as  a  tractor,  the  apex  of  the  cone-shaped  process  of 
the  stomach  wall  is  drawn  through  into  the  second  small  incision,  where 
it  is  fixed  with  four  to  six  interrupted  chromic  catgut  sutures.  The 
edges  of  the  skin  corresponding  to  the  first  incision  are  approximated 
with  several  interrupted  silkworm-gut  sutures.  The  conical  process 
of  the  stomach  wall  is  thus  buried  underneath  the  bridge  of  tissue 
between  the  two  incisions.  After  the  apex  of  the  cone-shaped  process 
of  the  stomach  has  been  sutured  to  the  second  small  incision,  it  may 
be  opened  and  a  tube  introduced  for  the  purpose  of  feeding.  A 
fistulous  tract  about  two  inches  long  which  is  bent  around  the  free 
border  of  the  ribs  and  leads  into  the  stomach  is  the  result. 

Witzel's  Method  is  a  most  satisfactory  operation.  An  incision 
is  made  below  and  parallel  with  the  free  border  of  the  ribs.  The 
incision  commences  about  one  and  one-half  inches  below  the  tip  of 
the  costal  cartilage  of  the  ninth  rib  and  is  carried  obliquely  downward 
and  outward  for  a  distance  of  two  or  three  inches.  The  integument 
and  aponeurosis  are  divided.    The  fleshy  fibers  of  the  internal  oblique 


Fig.  172. — Gastrostomy  (Ssabanajeiv-Franck).  A  cone-shaped  process  of  the 
anterior  wall  of  the  stomach  drawn  out  through  the  abdominal  incision  by  a  silk 
tractor  passed  through  its  apex;  the  base  of  the  process  is  sutured  all  around 
to  the  edges  of  the  parietal  peritoneum,  and  transversalis  fascia,  etc.,  in  the 
abdominal  incision. 


Fig.  173.— Gastrostomy  (Ssabnnajeic-FrruKk).  Apex  of  process  of  stomach 
drawn  through  the  second  incision  ready  for  suture.  Sutures  have  been  intro- 
duced for  the  purpose  of  closing  the  first  incision. 


378 


ABDOMEN  AND  BACK. 


are  exposed  and  the  fibers  separated  bluntly  with  the  handle  of  the 
knife ;  the  fleshy  fibers  of  the  transversalis  are  exposed  and  split  in  the 
same  manner  in  a  transverse  direction  corresponding  to  their  course. 
Thus  no  muscle  fibers  are  cut.  The  edges  of  the  incision  are  drawn 
apart  with  blunt  retractors  and  the  fascia  transversalis  and  peritoneum 
incised.  The  peritoneal  layer  is  picked  up  with  two  toothed  forceps 
and  carefully  incised  and  the  anterior  wall  of  the  stomach  seized  and 
drawn  out  through  the  incision. 

A  IsTo.  25  F.  soft-rubber  catheter  is  placed  upon  the  surface  of 
the  stomach  so  that  it  is  directed  obliquely  downward  and  toward  the 


Fig.  174.  —  Gastrostomy       (Wit-  Fig.  175.  —  Gastrostomy       (Wit- 

sel).     Sutures  that  infold  tlie  tube  ,zeU.    The  first  row  of  sutures  have 

in   the   wall    of   the    stomach    have  been  tied  and  the  tube  thus  buried 

been   introduced.     The  end    of   the  between   the  folds   of   the   stomach 

tube     projects     into     the     stomach  wall    which    have    been    raised    up 

through    a    small    incision    in    the  about    it.      A    second   row    of    con- 

wall  of  the  stomach.  tinuous  sutures  have  been  applied. 

Two  suspension  sutures,  A  and  B, 
have  been  introduced,  one  above 
and  the  other  below  the  point 
where  the  end  of  the  tube  emerges. 

right,  and  in  this  position  it  is  fixed  with  four  or  five  interrupted 
chromic  catgut  sutures  which  pick  up  the  wall  of  the  stomach  on  either 
side  of  the  catheter/ each  taking  a  good,  broad  bite,  but  not  penetrating 
through  the  entire  thickness  of  the  wall  of  the  stomach.  In  this  way 
the  stomach  wall  is  raised  in  a  fold,  or  plait,  upon  each  side  of  the 
tube  so  that  when  the  sutures  are  tied  the  two  folds  meet  and  com- 
pletely bury  the  tube.  Corresponding  to  the  end  of  the  catheter  a 
very  small  opening  is  made  in  the  stomach  wall  with  the  point  of  the 
knife,  and  through  this  the  end  of  the  catheter  is  pushed  so  that  about 
three  inches  of  its  length  is  within  the  stomach.  The  opening  in  the 
stomach  should  be  so  small  that  the  tube  will  be  a  tight  fit.    The  end 


OPERATIONS  UPON  THE  STOMACH.  379 

of  the  tube  is  secured  near  the  edge  of  the  incision  in  the  stomach  with 
a  single  fine  chromic  catgut  stitch  so  that  the  tube  cannot  become 
displaced.  The  free  end  of  the  tube  is  closed  with  a  ligature  or  forceps 
to  prevent  the  escape  of  stomach  contents.  The  four  or  five  sutures, 
which  have  been  introduced  across  the  tul)e  into  the  stomach  wall  are 
tied  and  tlius  the  tube  is  imbedded  between  the  two  folds  of  the 
stomach  wall  which  form  a  canal  al^out  the  tube.  An  additional  line  of 
suture  is  introduced  to  secure  the  accurate  coaptation  of  the  two  folds 
of  the  stomach  wall  over  the  tul)e,  and  at  the  point  where  the  end  of 
the  tube  penetrates  the  stomach  the  sutures  are  extended  a  sufficient 
distance  beyond  to  insure  against  leakage  from  the  stomach  around 
the  tube.  This  line  of  suture  is  continuous,  non-penetrating,  of  fine 
catgut.  That  part  of  the  stomach  wall  which  is  immediately  adjacent 
to  the  end  of  the  catheter  as  it  emerges  from  the  canal  formed  by  the 
folding  of  the  wall  of  the  stomach  is  secured  with  two  non-penetrating 
sutures  of  chromic  catgut.  These  sutures  are  used  to  fix  the  stomach 
to  the  edges  of  the  parietal  peritoneum  and  transversalis  fascia  in  the 
abdominal  incision.  Each  of  these  sutures  takes  several  good,  broad 
bites  in  the  wall  of  the  stomach,  but  should  not  pass  through  its 
entire  thickness.  One  of  the  sutures  is  placed  above  the  point  where 
the  tube  emerges  and  the  other  below.  They  serve  to  suspend  that  part 
of  the  wall  of  the  stomach  which  is  immediately  adjacent  to  the  tube, 
to  the  parietal  peritoneum. 

The  abdominal  incision  is  closed  except  where  the  tube  emerges. 
The  edges  of  the  peritoneum  and  transversalis  fascia  are  sewed 
together  with  several  sutures  of  plain  catgut.  These  are  introduced 
before  the  suspension  sutures  are  tied.  The  edges  of  the  split  muscles 
return  into  close  approximation.  The  edges  of  the  aponeurosis  are 
united  with  a  chromic  catgut  suture  and  finally  the  skin  with  several 
sutures  of  silk-worm  gut. 

Kader  Method. — An  excellent  procedure.  The  incision  is  made 
about  one  inch  below  and  parallel  with  the  left  free  border  of  the 
ribs,  about  three  inches  long,  the  upper  end  of  the  incision  opposite 
the  tip  of  the  eighth  costal  cartilage.  Instead  of  cutting  the  mus- 
cular layers,  the  operator  may  penetrate  bluntly,  separating  between 
their  fibers.  The  transversalis  fascia  and  parietal  peritoneum  are 
incised  in  an  oblique  direction,  along  the  same  line  as  the  integument. 
Some  operators  prefer  the  vertical  incision,  made  over  the  middle  of 
the  left  rectus,  commencing  above  about  one  inch  below  the  free  border 
of  the  costal  cartilage,  carried  downward  for  about  three  inches. 


380  ABDOIvIEN  AND  BACK. 

A  portion  of  the  anterior  wall  of  the  stomach  is  seized  with  the 
fingers  and  brought  out  through  the  abdominal  incision.  Pads  are 
placed  to  protect  the  parts  and  a  very  small  opening  is  made  in  this 
part  of  the  stomach  with  the  knife.  A  soft-rubber  catheter  about  as 
big  around  as  a  lead-pencil  is  introduced  through  this  incision,  into  the 
stomach  for  about  two  inches  and  fixed  to  the  edge  of  the  incision  with 
a  single  catgut  suture. 

Four  sutures  are  then  introduced  in  the  wall  of  the  stomach,  two 
above  the  catheter  and  two  below.  These  sutures  are  of  chromic  catgut, 
of  the  non-penetrating,  Lembert  variet}^  They  are  placed  about  one- 
third  of  an  inch  apart  and  take  a  good  broad  bite  penetrating  through 
the  serous  and  muscular  coats.  When  these  sutures  are  tied  they  serve 
to  raise  the  wall  of  the  stomach  up  around  the  catheter  in  the  shape 
of  two  folds  which  have  the  effect  of  infolding  the  catheter  into  the 
lumen  of  the  stomach  for  a  depth  of  about  one-half  inch.  A  second 
tier  of  four  sutures  is  introduced  in  a  similar  manner,  picking  up  the 
wall  of  the  stomach  about  one-half  inch  beyond  the  first  row  upon  each 
side,  burying  these  and  at  the  same  time  still  further  infolding  the 
catheter  into  the  cavity  of  the  stomach.  A  third  tier  of  sutures  may 
be  employed,  but  these  are  usually  unnecessary. 

The  stomach,  the  portion  immediately  adjacent  to  the  catheter 
as  it  emerges  from  the  canal  formed  by  the  infolded  portion  of  the 
wall  of  the  stomach,  is  fixed  to  the  edges  of  the  parietal  peritoneum 
and  transversalis  fascia  in  the  abdominal  incision  with  two  suspension 
sutures,  one  above  and  the  other  below  the  point  where  the  tube 
emerges.  These  sutures  are  of  chromic  catgut  and  do  not  penetrate 
the  entire  thickness  of  the  wall  of  the  stomach,  but  the  serous  and 
muscular  coats  only. 

The  abdominal  incision  is  closed  except  for  the  small  space 
through  which  the  catheter  emerges  in  a  manner  similar  to  that 
described  in  the  preceding  operation. 

Gastrorrhaphy. — Suture  of  the  wall  of  the  stomach  for  perfora- 
tion due  to  ulcer  or  stab  or  gunshot  wounds.  The  surgeon  should 
remember,  in  connection  with  stab  and  gunshot  wounds,  that  the 
pancreas  from  its  position  is  especially  liable  to  be  injured  also. 

Ulcer  more  commonly  affects  the  posterior  wall  of  the  stomach 
than  the  anterior  wall.  Perforation  due  to  ulcer,  however,  is  more 
frequently  met  with  in  the  anterior  wall.  There  may  be  more  than 
one  perforation.  The  stomach  should  not  be  washed  out  before 
operating  if  perforation  is  suspected.     An  incision  is  made  in  the 


OPERATIONS  UPON  THE  STOMACH.  381 

middle  line  through  the  linea  alba  from  a  point  just  l>elow  the  ensi- 
form  process  to  the  umbilicus  and  the  stomach  exposed. 

The  entire  stomach  should  be  carefully  explored,  first  the  ante- 
rior wall  and  then  the  posterior.  In  order  to  explore  the  posterior 
wall  an  opening  may  be  torn,  not  cut,  in  the  gastro-colic  ligament  or 
preferably  in  some  cases  in  the  transverse  mesocolon.  Through  the 
opening  thus  made  access  may  be  had  to  the  posterior  wall  of  the 
stomach. 

If  the  wound  in  the  stomach  is  small,  it  may  be  closed  with  a 
non-penetrating  purse-string  suture  or  with  a  single  row  of  Lembert 
sutures  of  silk.  These  sutures  take  a  good,  broad  bite  in  the  wall  of 
the  stomach,  and  should  include  the  serous  and  muscular  coats  only; 
they  do'  not  pierce  the  entire  thickness  of  the  wall  of  the  stomach  or 
enter  the  mucous  membrane  layer.  It  is  well  to  reinforce  the  first 
row  of  Lembert  sutures  with  a  second  row.  If  the  wound  in  the 
stomach  is  large,  for  example,  after  excision  of  a  portion  of  the  wall 
of  the  stomach  for  ulcer,  etc.,  the  opening  may  be  closed  with  a  con- 
tinuous, through-and-through  suture  of  chromic  catgut  and  then  in 
addition  to  this  a  row  of  continuous  Lembert  sutures  of  silk  are 
applied.  These  bury  the  through-and-through  catgut  stitch  and  bring 
the  serous  edges  into  accurate  apposition. 

If  there  is  difficulty  in  closing  the  perforation  by  suture,  owing 
to  dense  adhesions,  etc.,  it  might  be  plugged  up  by  applying  a  piece 
of  omentum  or  a  coil  of  intestine  against  it  and  fixing  it  by  suture 
to  the  stomach. 

If  the  peritoneum  has  become  soiled  by  escaping  stomach  contents, 
it  is  well  to  thoroughly  flush  out  the  abdominal  cavity  with  salt  solu- 
tion after  the  opening  in  the  stomach  has  been  closed. 

Gastroplasty. — The  steps  of  this  operation  are  quite  analogous  to 
those  described  in  the  p3-loroplasty  of  Heinecke  and  Mikulicz.  For 
hour-glass  contraction  of  the  stomach  due  to  cicatrization,  etc.,  de- 
pendent upon  chronic  ulcer. 

The  stomach  should  be  emptied  before  the  operation  is  commenced, 
just  before  the  patient  is  anesthetized,  with  the  stomach  tube.  The 
stomach  is  reached  through  an  incision  in  the  middle  line,  commencing 
just  below  the  ensiform  cartilage  and  reaching  down  to  the  umbilicus. 

A  transverse  incision  is  made  in  the  constricted  part  of  the 
stomach,  penetrating  through  the  entire  thickness  of  the  stomach 
wall  and  reaching  from  one  pouch  into  the  other.  Bleeding  points 
are  clamped  and  ligated  with  catgut.     The  edges   of  the   incision 


383  ABDOMEN  AND  BACK. 

are  then  drawn  apart  with  two  tenacula  which  are  hooked  in  the  edges 
of  the  incision,  abont  the  middle,  so  that  the  transverse  incision 
becomes  converted  into  a  vertical  one.  The  edges  of  the  incision  while 
they  are  held  thus  are  sutured  together:  first  with  a  sufficient  num- 
ber of  interrupted,  through-and-through  stitches  of  chromic  catgut 
which  close  the  opening,  and  then  with  one  or  two  rows  of  Lembert 
sutures  of  silk.  The  latter  may  be  interrupted  or  continuous  and 
should  take  a  good,  broad  bite  in  the  stomach  wall. 

This  operation  is  probably  not  so  satisfactory  where  chronic 
ulcer  exists  as  the  operation  of  gastro-gastrostomy  combined  with 
gastro-jejunostomy  as  described  in  the  next  paragraphs. 

Gastro-gastrostomy. — ^The  establishment  of  an  artificial  commu- 
nication between  parts  of  the  stomach.  The  operation  is  done  for 
the  relief  of  symptoms  due  to  hour-glass  contraction,  the  result 
of  cicatrization,  etc.,  of  ulcer  affecting  the  body  of  the  stomach. 
In  exaggerated  cases  the  stomach  may  be  found  separated  into  two 
distinct  pouches  communicating  with  one  another  through  an  open- 
ing so  constricted  as  barely  to  admit  the  end  of  the  finger.  The 
object  of  the  operation  is  to  provide  a  liberal  opening  between  both 
pouches  which  will  readily  permit  the  discharge  of  the  stomach 
contents  from  the  proximal  into  the  distal  pouch  and  at  the  same 
time  avoid  the  passage  of  the  foodstuffs  over  the  ulcerated  area. 
Under  these  favorable  conditions  ulcers  will  often  heal  rapidly. 

The  stomach  (proximal  pouch)  should  be  emptied  with  the 
stomach  tube  immediately  before  operating  and  after  the  patient 
has  been  anaesthetized  or,  if  this  has  not  been  done,  then,  when 
the  stomach  is  exposed,  the  contents  may  be  expressed  from  the 
stomach  into  the  duodenum.  The  incision  is  placed  in  the  middle 
line,  commencing  about  one  inch  below  the  tip  of  the  ensiform 
process  and  reaching  downward  to  the  umbilicus;  it  can  be  still 
further  lengthened  if  necessary. 

After  the  abdomen  has  been  opened  the  stomach  is  sought.  It 
may  be  found  separated  into  two  pouches  of  nearly  equal  size  or 
the  upper,  cardiac  pouch  may  be  quite  small  and  concealed  above, 
underneath  the  ribs.  Care  must  be  exercised  in  dealing  with  adlie- 
sions.  The  stomach  may  be  adherent  to  the  anterior  abdominal 
wall,  and  the  breaking  down  of  these  adhesions  may  show  a  perfora- 
tion leading  into  the  stomach;  this  may  be  closed  by  infolding  all 
of  the  ulcerated  area  and  the  application  of  one  or  two  rows  of 
Lembert  sutures.     The  operator  should  not  be  precipitate  in  break- 


OPERATIONS  UPON  THE  STOMACH.  383 

ing  down  adhesions  between  the  stomach  and  the  adjacent  organs, 
especially  the  pancreas  and  liver;  it  is  well  in  most  cases  not  to 
disturb  these  adhesions,  as  at  times  they  serve  to  close  up  an 
opening  into  the  stomach,  the  result  of  deep  ulceration. 

The   two   pouches    of   stomach   are    drawn    into    the    abdominal 
incision  or,   if  possible,   outside  upon  the   abdomen   and   after  pads 


Fig.  176. — Gastro-gastrostomy.  The  two  stomach  pouches  have  been  joined 
together  with  a  row  of  continuous  Lembert  sutures  and  each  has  been 
incised. 

have  been  properly  arranged  to  protect  the  peritoneal  cavity  the 
anastomosis  is  made  in  a  manner  similar  to  that  described  in  gastro- 
jejunostomy. The  two  pouches  are  joined  together,  side  by  side, 
with  a  continuous,  non-penetrating  silk  suture  carried  in  a  straight 
cambric  needle.  The  parts  should  be  united  thus,  in  a  straight 
line,  for  a  distance  of  two  and  one-half  or  three  inches  if  possible. 
This  line  of  suture  forms  the  posterior  half  of  the  "outside  serous 


384  ABDOMEN  AND  BACK. 

ring."  An  incision  is  then  made  into  each  ponch  from  two  to  two^ 
and  one-half  inches  long,  parallel  with  and  about  one-quarter  inch 
distant  from  the  line  of  suture  that  has  been  applied.  These 
incisions  should  be  shorter  than  the  line  of  suture.  The  contiguous 
margins  of  the  two  openings  are  then  united  to  each  other,  all 
around,  with  a  continuous  penetrating  suture  of  catgut.  After  this 
line  of  suture  has  been  completed,  the  edges  of  the  openings  having 
been  joined  to  each  other  all  around,  the  needle,  carrying  the  thread 
of  the  first  non-penetrating  Lembert  suture  and  which  was  tem- 
porarily laid  aside,  is  again  taken  in  hand  and  the  anterior  half 
of  the  non-penetrating  suture- — -"outside  serous  ring'^ — is  applied. 
This  serves  to  bury  the  penetrating  catgut  sutures  that  unite  the 
edges  of  the  openings  in  both  ptouches  and  thus  completes,  the 
anastomosis.  The  j)arts  are  wiped  clean  with  a  pad  wet  with  hot 
saline  solution  and  returned  into  the  abdomen.  One  should  care- 
fully investigate  the  condition  of  the  pylorus,  and  if  any  constric- 
tion is  discovered  a  gastro-jejunostomy  should  be  performed,  in 
addition  to  the  gastro-gastrostom}^,  the  junction  being  made  between 
the  distal,  pyloric,  pouch  and  the  upper  part  of  the  jejunum.  The 
abdominal  incision  is  closed  layer  by  la,jer. 

For  the  relief  of  hour-glass  contraction  where  the  presence 
of  adhesions  precludes  the  performance  of  a  gastro-gastrostomy, 
a  gastro-jejunostomy  may  be  made  between  the  proximal,  cardiac, 
pouch,  and  the  intestine.  The  operator  must  be  certain  to  secure 
this  part  of  the  stomach;  it  may  be  the  smaller  of  the  two  pouches 
and  concealed  beneath  the  ribs. 

This  operation  may  be  done  with  the  clamps  in  a  manner  similar 
to  the  "Gastro-jejunostomy,  Clamp  Method." 

Gastrectomy. — Excision  of  the  stomach  may  be  partial  or  com- 
plete.   The  partial  may  be  either  atypical  or  cylindrical. 

Partial  Atypical  Gastrectomy. — Excision  of  a  limited  portion  of 
the  wall  of  the  stomach,  without  interruption  of  the  continuity  of 
the  organ;  for  non-malignant  ulcer  (see  also  gastrotomy  for  bleeding 
ulcer).  The  operation  is  indicated  in  those  cases  where  the  ulcerated 
area  is  limited  and  accessible. 

The  stomach  is  exposed  through  an  incision  in  the  linea  alba. 
Adhesions  that  are  encountered  are  gently  broken  down  with  the 
fingers  and  the  diseased  portion  brought  into  view  and  excised.  A 
diseased  area  of  the  posterior  wall  may  be  excised  from  within  the 
stomach,  working  through  an  opening  made  in  its  anterior  wall,  or 


OPERATIONS  UPON  THE  STOMACH.  385 

else  this  portion  of  the  stomach  may  be  made  accessible  by  tearing 
through  the  gastro-colic  ligament  or  through  the  transverse  meso- 
colon as  described  in  the  operation  of  "Posterior  Gastro-jejunos- 
tomv."  The  opening  that  remains  in  the  stomach  after  the  ulcer- 
ated area  has  been  excised  is  closed  with  a  throngh-and-throngh 
sutnre  of  chromic  catgnt,  which  is,  in  turn,  reinforced  and  buried 
by  a  continuous  Lembert  suture  of  silk.  The  through-and-through 
suture  controls  the  bleeding  from  the  edges  of  the  stomach  wound. 
Spurting  vessels  may  be  clamped  and  ligated  with  catgut.  Mitchell 
has  suggested  that  simple  infolding  of  the  diseased  area  without 
excision  would  answer  very  well  in  many  of  these  cases. 

This  plan  of  excision  of  the  ulcer  can  only  be  applied  to  those 
cases  where  the  diseased  portion  of  the  stomach  can  be  made 
accessible.  It  would  be  rather  more  difficult  to  follow  this  method 
of  treatment  if  the  ulcer  involved  the  posterior  wall  or  in  cases 
of  deep  ulceration  with  firm  adhesions  between  the  stomach  and 
adjacent  organs, — liver,  pancreas,  etc.  Under  these  conditions  the 
operator  might  wisely  content  himself  with  a  gastro-jejunostomy. 
It  would  probably  be  advisable  in  all  these  cases  to  establish  a  gastro- 
jejunostomy in  addition  to  excising  the  ulcerated  area,  etc.,  because 
stenosis  of  the  pylorus  is  associated  with  the  condition  of  chronic 
ulcer  in  a  considerable  number  of  cases. 

Partial  Cylindrical  Gastrectomy. — Eesection  of  an  entire  seg- 
ment of  the  stomach.  May  be  of  the  pyloric  portion  only,  pylo- 
rectomy;  or  the  pylorus  and  a  considerable  part  of  the  body  of  the 
stomach  may  be  resected,  the  partial  gastrectomy  of  Hartmann, 
Mayo,  and  Moynihan. 

Pyloeectomy. — Eesection  of  the  pyloric  portion  of  the  stomach. 
This  operation  has,  until  recently,  been  the  routine  one  practiced 
for  operable  cases  of  malignant  disease  of  the  pylorus;  but  in  the 
light  of  recent  experience  the  more  extensive  oijerations  of  Hart- 
mann and  of  Mayo  are  to  be  preferred  in  all  cases  of  malignant 
disease  of  the  stomach  even  if  the  condition  is  apparently  still  con- 
fined to  the  pylorus.  The  operation  of  pylorectomy  is  indicated 
in  some  cases  of  chronic  non-malignant  ulceration  limited  to  the 
pyloric  portion  of  the  stomach. 

The  incision  is  placed  in  the  middle  line  and  should  be  suffi- 
ciently large,  extending  from  the  ensiform  process  down  to  the 
umbilicus  or  beyond  this  point  if  necessary.  The  pyloric  end  of 
the   stomach  is  drawn  into   the  wound  and  well   surrounded  with 

25 


386 


ABDOMEN  AND  BACK. 


gauze  pads  and  the  left  lobe  of  the  liver  is  held  up  out  of  the  way  by 
an  assistant. 

Billroth's  First  Method. — The  first  step  in  the  operation  is  to 
secure  and  ligate  the  vessels  that  course  along  the  upper  and  lower 
borders  of  the  stomach.     Corresponding  to  the  upper  border,  near 


Pig.  177.— Pylorectomy.  Anterior  edge  of  the  liver  is  lifted  up;  the  lesser 
and  greater  omenta  are  shown.  The  lesser  and  greater  omenta,  correspond- 
ing to  the  portion  of  the  stomach  that  is  to  be  excised,  have  been  ligated  in 
sections.  The  dotted  lines  indicate  the  line  of  section  through  the  stomach 
and  omenta.  Instead  of  being  applied  as  represented  in  this  picture,  the 
ligatures  may  be  placed  double  and  the  line  of  incision  carried  between  them. 

the  pyloric  end  is  the  pyloric  artery,  a  branch  of  the  hepatic; 
toward  the  cardiac  end  of  the  stomach  is  the  gastric.  Correspond- 
ing to  the  lower  border  we  have  the  gastro-epiploica  dextra  coming 
from  the  right,  and  the  gastro-epiploica  sinistra  tfi^om  the  left. 
These  vessels  should  be  ligatured  with  plain  catgut.     The  next  step 


OPERATIONS  UPON  THE  STO:\IACH. 


387 


of  the  operation  consists  in  the  detachment  of  the  pylorus  (dis- 
eased part  to  be  excised)  from  the  greater  omentum  below  and 
from  the  lesser  omentum  above.  With  a  blunt-pointed  ligature 
carrier,  armed  with  catgut,  the  greater!  and  lesser  omenta,  corre- 
sponding to  the  diseased  pylorus,  are  transfixed  and  tied  off  in 
sections.  Each  ligature  should  include  from  one  to  one  and  one- 
half  inches  of  the  omentum,  and  should  be  applied  double  so  that 
when  the  operator  divides  each   segment  of  the   ligated   omentum, 


Fig.  178.— Pylorectomy  (Billroth).     Shaded  part  indicates  the  portion  of  the 
stomach  that  is  resected. 


he  may  do  so  between  the  ligatures.  Usually  two  or  three  ligatures 
will  suffice  for  the  lesser  omentum,  gastro-hepatic  ligament,  and 
three  or  four  for  the  greater  omentum,  gastro-colic  ligament.  One 
should  be  mindful  of  the  location  of  the  common  bile-duct  and  the 
portal  vein  in  the  free  right  edge  of  the  lesser  omentum.  After 
the  pylorus  has  been  thus  separated,  cut  away,  from  its  omental 
attachment  above  and  below,  the  hand  is  passed  over  the  lesser 
curvature  into  the  lesser  peritoneal  cavity  and  down  behind  the 
stomach  to  thoroughly  separate  it  posteriorly.  The  detached  pyloric 
portion  of  the  stomach,  after  it  has  been  thus  separated,  may  be 
drawn  pretty  well  out  through  the  abdominal  incision,  so  that  the 
subsequent  steps  of  the  operation  may  be  executed  with  more  ease. 


388  ABDOMEN  AND  BACK. 

Before  excising  the  diseased  portion  of  the  stomach,  clamps 
are  applied  about  the  duodenum  and  about  the  stomach.  Two  pair 
of  short,  narrow-bladed  clamps  are  applied  to  the  duodenum.  Of 
the  two  clamps  the  one  nearer  the  pylorus  is  a  crushing  clamp;  the 
other,  which  is  j)laced  farther  along  on  the  duodenum,  about  one 
inch  distant  from  the  first  clamp,  is  an  elastic-bladed,  rubber- 
sheathed  holding  clamp.  Two  long-bladed  clamps  are  applied 
across  the  stomach,  one  inch  or  more  distant  from  the  diseased 
portion  of  the  stomach.  These  two  clamjDS  are  applied  parallel 
to  each  other  and  about  one  inch  apart,  so  as  to  leave  ample  space 
between  them  for  dividing  the  stomach.  Of  these  two  clamps  the 
one  nearer  the  pylorus  (diseased  portion)  is  a  crushing  clamp,  the 
other  an  elastic-bladed  holding  clamp — the  blades  sheathed  with 
rubber  tubing.  The  stomach  is  divided  between  the  two  clamps,  cut- 
ting rather  close  to  the  crushing  clamp  with  the  scissors.  The  stump 
of  the  pylorus  (diseased  portion)  enveloped  in  a  compress  is  turned 
over  toward  the  right  side,  the  crushing  clamp  which  is  still  applied 
preventing  any  leakage.  Hemorrhage  from  the  cut  end  of  the 
stomach  is  controlled  by  the  holding  clamp.  Any  spurting  points 
are  caught  with  artery  clamps  and  ligatured;  oozing  and  venous 
hemorrhage  cease  when  the  cut  end  of  the  stomach  has  been  closed 
by  suture.  The  cut  end  of  the  stomach,  except  for  the  lower  part 
which  is  left  open  to  receive  the  end  of  the  duodenum,  is  closed 
with  a  continuous  through-and-through  suture  of  chromic  catgut. 
This  suture  unites  the  cut  edges  of  the  stomach  that  protrude 
between  the  blades  of  the  holding  clamp.  The  suture  is  commenced 
above,  working  downward  toward  the  greater  cur^'^ature.  It  is  ap- 
plied with  a  straight  needle  and  in  such  a  manner  as  to  invert 
the  edges  of  the  stomach.  Each  stitch  is  drawn  fairly  tight.  The 
lower  part  of  the  opening  in  the  stomach  is  left  unclosed  for  a 
length  sufficient  to  allow  for  the  implantation,  later,  of  the  end  of 
the  duodenum.  A  second  line  of  suture,  a  continuous,  non-pene- 
trating Lembert  suture  of  silk,  is  introduced.  This  suture  inverts 
and  buries  the  first  line  of  suture,  the  through-and-through  catgut 
suture.  The  end  of  the  ■  stomach  is  wrapped  in  a  compress  and 
temporarily  laid  aside,  and  the  attention  of  the  operator  is  directed 
to  the  duodenum. 

The  duodenum  is  divided  between  the  two  clamps,  rather  close  to 
the  crushing  clamp,  and  the  resection  of  the  pylorus  is  thus  accom- 
plished.   The  end  of  the  duodenum  that  protrudes  between  the  blades 


OPERATIONS  UPON  THE  STO^L^CII. 


389 


of  the  rubber-sheathed  holding  clamp  is  wiped  clean  with  a  gauze 
compress. 

After  the  protecting  gauze  pads  have  been  renewed  the  end  of  the 
duodenum  is  sutured  into  the  opening  that  has  been  left  in  the  stomach. 


Fig.  179.— Restoration  of  the  Gastro-intestinal  Canal,  Billrotli's  First  Method. 
The  posterior  half  of  the  non-penetrating,  "outside  serous  ring"  suture  has 
been  applied. 

The  end  of  the  duodenum  is  Joined  to  the  margin  of  the  opening  in  the 
stomach  with  a  continuous  non-penetrating  suture  of  silk.  This  suture 
catches  the  wall  of  the  duodenum  about  one-quarter  inch  beyond  its 
cut  edge  and  Joins  it  to  the  wall  of  the  stomach  about  one-quarter  inch 
away  from  the  edge  of  the  opening.  This  suture  is  applied  only  half- 
way around   (the  posterior  half)    and  then  the  needle  is  laid  aside 


390  ABDOMEN  AND  BACK. 

until  required  later  to  complete  this  outside  ring  of  suture.  With  a 
through-and-through  sutvire  of  chromic  catgut  the  edge  of  the  duo- 
denum is  accurately  sewed  all  around  to  the  edge  of  the  opening  in 
the  stomach.  After  this  line  of  suture  has  been  completed  the  needle 
carrying  the  silk  thread  with  which  the  posterior  half  of  the  outside, 
non-penetrating  suture  was  applied  is  again  taken  in  hand  and  the 
operation  completed  by  introducing  the  anterior  half  of  the  non- 
penetrating suture.  Special  care  should  be  exercised,  in  making  the 
anastomosis  of  the  end  of  the  duodenum  to  the  stomach,  to  accurately 
secure  the  point  where  the  perpendicular  line  of  suture,  that  which 
closes  the  end  of  the  stomach,  meets  the  circular  suture  that  joins  the 
end  of  the  duodenum  to  the  stomach. 

Billroth's  Second  Method. — This  opreation  differs  from  the 
one  Just  described  only  in  the  part  that  has  to  do  with  the  restoration 
of  the  continuity  of  the  alimentary  canal,  and  is  to  be  preferred  to 
it  especially  if  the  stump  of  the  duodenum  is  short  or  fixed. 

After  the  pylorus  has  been  resected,  the  end  of  the  stomach  and 
the  end  of  the  duodenum  are  both  closed  completely  by  inversion  and 
suture  and  a  posterior  gastro-jejunostomy  then  made.  According  to 
Billroth,  the  gastro-jejunostomy  is  made  with  simple  suture,  but  any 
of  the  methods  described  (see  "Gastro-jejunostomy'^)  may  be  em- 
ployed for  this  step  of  the  operation.     (See  Fig.  186.) 

Method  op  Kooher  (PtESECTioisr  oe  the  Pylorus,  with  GtAstro- 
duodenostomy)  . — The  abdominal  cavity  is  opened  through  an  incision 
as  described  in  the  preceding  operation  and  the  portion  of  the  stom- 
ach which  is  to  be  removed,  the  pyloric  portion  or  maybe  the  greater 
part  of  the  body  of  the  stomach  if  for  malignant  disease,  is  separated 
from  its  attachments  above  and  below.  The  greater  and  lesser 
omenta  and  the  vessels  that  supply  the  stomach  are  ligated  in  a 
manner  similar  to  that  described  in  Billroth's  First  Method. 

After  the  portion  of  the  stomach  which  is  to  be  resected  has 
been  isolated  and  separated  above  and  below,  it  can  be  lifted  out 
of  the  incision  provided  it  is  not  adherent  to  the  pancreas,  trans- 
verse mesocolon,  etc.,  and  the  operation  can  be  continued  with 
more  facility.  Two  heavy  holding  clamps  with  bare  blades  are 
applied  to  the  stomach,  reaching  from  the  greater  to  the  lesser  curva- 
ture. These  are  applied  fairly  close  together  and  at  least  two  fingers' 
breadth  away  from  the  external  limit  of  the  diseased  area.  The 
stomach  is  divided  with  the  scissors  between  the  two  clamps,  cutting 
close  up  against  the  second  clamp,  that  one  which  is  applied  toward 


OPERATIONS  UPON  THE  STOMACH.  391 

the  healthy  portion  of  the  stomach.  The  edge  of  the  stump  of  the 
stomach  still  held  in  the  clamp  is  wiped  clean  with  a  gauze  pad  wet  in 
alcohol.  The  stump  of  the  stomach  secure  in  the  grasp  of  the  clamp 
is  then  wrapped  in  a  compress  and  laid  aside  temporarily.  The  dis- 
eased part  of  the  stomach  in  the  grasp  of  the  other  clamp  is  turned 
over  toward  the  right  side.  Traction  is  made  on  the  duodenum  to 
ascertain  whether  the  duodenum  is  sufficiently  free  and  movable  to  be 
brought  up  into  apposition  with  the  stomach  for  anastomosis  after  the 
resection  has  been  completed.  Two  straight  forceps  with  bare  blades 
are  applied  to  the  duodenum  quite  close  together  and  well  beyond  the 
diseased  limits,  and  the  duodenum  is  divided  between  them.  The  dis- 
eased portion  of  the  stomach  is  thus  removed.  The  cut  edge  of  the 
duodenum  grasped  between  the  blades  of  the  holding  clamp  is  wiped 
clean  with  a  pad  wet  with  alcohol. 

The  forceps  wliich  grasps  the  end  of  the  stomach  is  taken  up  and 
steadied  by  the  assistant  and  the  end  of  the  stomach  closed  with  a 
chromic  catgut  suture  carried  in  a  long  straight  needle.  The  suture 
is  applied  through-and-through  proximal  to  the  blades  of  the  crushing 
forceps.  After  the  suture  has  been  introduced  the  forceps  is  removed 
and  if  the  edge  of- the  stomach  beyond  the  suture  line  is  too  wide  it 
may  be  trimmed  away.  If  there  is  any  hemorrhage  from  the  edge  of 
the  stomach  the  bleeding  points  may  be  clamped  and  ligated.  A 
second  line  of  suture  is  introduced.  This  suture,  of  silk,  penetrates 
the  serous  and  muscular  coats  only  and  inverts  the  edges  and  buries  the 
first  line  of  suture.  A  third  non-penetrating  line  of  suture,  silk,  may 
be  introduced  and  this  in  turn  buries  the  second  line. 

The  stump  of  the  stomach  is  held  up  and  steadied  by  an  assist- 
ant and  the  end  of  the  duodenum  still  in  the  grasp  of  the  holding 
forceps  is  brought  up  close  to  the  stomach.  The  duodenum  just 
beyond  the  edge  which  is  held  between  the  blades  of  the  forceps  la 
sutured  to  the  posterior  wall  of  the  stomach,  low  down,  parallel  with 
and  close  to  the  line  of  suture  that  closes  the  end  of  the  stomach — 
within  two  inches.  This  is  accomplished  with  a  continuous  non-pene- 
trating suture  of  silk.  After  the  posterior  half  of  the  circumference  of 
the  stump  of  the  duodenum  has  been  sutured  to  the  wall  of  the  stomach, 
the  clamp  is  removed  from  the  end  of  the  duodenum  and  the  needle, 
still  carrying  the  thread  which  was  used  to  sew  the  duodenum  to  the 
stomach,  is  temporarily  laid  aside.  Before  the  clamp  is  removed  from 
the  end  of  the  duodenum  a  strip  of  narrow  tape  is  passed  around  the 
duodenum   or  a  compressor   clamp   with   rubber-sheathed   blades   is 


392 


ABDOMEN  AND  BACK. 


applied  so  as  to  prevent  the  escape  of  contents  from  the  duodenum 
when  the  clamp  is  removed.  The  stomach  is  incised  just  in  front  of 
and  parallel  with  the  line  of  suture  that  joins  the  end  of  the  duodenum 
to  it.  Hemorrhage  from  the  incision  in  the  stomach  is  controlled  by 
clamping  and  ligating  bleeding  points.     With  a  through-and-through 


Fig.  180. — Pylorectomy  (Eocher).  Stump  of  the  duodenum  has  been  joined 
to  the  posterior  wall  of  the  stomaeh  by  a  row  of  continuous  Lembert  sutures. 
Opening  has  been  made  in  the  stomach  to  receive  the  end  of  the  duodenum. 


chromic  catgut  suture  the  edge  of  the  duodenum  is  united  to  the  edge 
of  the  incision  on  the  stomach  all  around.  This  suture  includes  all 
the  coats,  especial  care  to  include  the  edges  of  the  mucous  membrane. 
After  the  end  of  the  duodenum  has  thus  been  sutured  to  the  opening 
in  the  stomach  all  around  the  needle,  carrying  the  silk  thread  with 
which  the  posterior  half  of  the  non-penetrating  suture  that  joins  the 
duodenum  to  the  stomach  was  introduced,  is  again  taken  in  hand  and 


OPERATIONS  UPON  THE  STOMACH. 


393 


the  anastomosis  completed  by  introducing  the   anterior  half   of  the 
outside,  non-penetrating  ring  suture. 

Hartmann's  Method  of  Gasteectomy. — The  partial  gastrec- 
tomy, according  to  the  method  of  Hartmann,  is  performed  for 
cancer  of  the  pyloric  portion  of  the  stomach,  and  is  based  upon  the 
normal  arrangement  of  the  lymphatics  of  the  stomach.     It  consists 


Fig.  ISl. — Doyen  Holding  Forceps. 


of  resection  of  the  pylorus  and  part  of  the  body  of  the  stomach 
and  the  adjacent  lymphatic  nodes.  The  pylorns  is  drained  chiefly 
by  the  lymphatics  that  terminate  in  the  nodes  situated  along  the 
lesser  curvature — along  the  course  of  the  gastric  artery — ^between 
the  folds  of  the  gastro-hepatic  omentum,  and  for  this  reason  cancer 
originating   in   the   pylorus,   the  usual   site   of   the    disease,    spreads 


Fig.  182. — Hartmann  Holding  Forceps. 

more  rapidly  along  the  lesser  curvature  than  along  the  greater 
curvature  (see  Fig.  160),  involving  not  only  the  lymphatic  nodes, 
but  also  affecting  the  mucous  membrane  of  this  part  of  the  organ 
early.    The  fundus  is  not  affected  until  late  in  the  disease. 

In  this  operation  the  pylorus  and  body  of  the  stomach,  all 
of  the  lesser  curvature,  and  a  considerable  part  of  the  greater 
curvature,  together  with  all  the  adjacent  lymphatic  nodes  are 
removed  in  one  mass,  the  fundus   only  remaining;  the  continuity 


394  ABDOMEN  AND  BACK. 

of  the  alimentary  canal  is  restored  either  by  a  gastro-duodenostomy 
or  a  gastro-Jejnnostomy. 

The  abdominal  incision  must  be  sufficiently  liberal,  reaching 
from  the  tip  of  the  ensiform  cartilage  downward  in  the  middle  line 
as  far  as  the  umbilicus  or  beyond  that  point.  The  hand  is  intro- 
duced into  the  abdomen  and  the  conditions  investigated.  As  a 
rule,  the  stomach,  tumor,  can  be  brought  out  through  the  incision. 
If  the  tumor  cannot  be  drawn  out  thus,  because  fixed  by  dense 
adhesions  and  by  the  extension  of  the  disease  to  the  surrounding 
organs, — pancreas,  liver,  spleen,  diaphragm,  etc., — ^then  the  case  is 
probably  not  a  suitable  one  for  this  radical  operation,  but  rather 
for  a  palliative  gastro-jejunostomy.  Inflammatory  adhesions  that 
are  not  too  dense  may  be  broken  up  with  the  fingers.  The  liver, 
etc.,  are  retracted  upward  by  the  assistant  and  the  stomach  seized 
by  the  operator  and  drawn  downward  and  the  index  finger  of  the 
left  hand  poked  through  the  gastro-hepatic  omentum.  In  this  way 
the  operator  is  able  to  explore  the  posterior  wall  of  the  stomach, 
the  lymphatic  nodes  in  the  gastro-hepatic  omentum  along  the  lesser 
curvature,  and  also  locate  the  gastric  artery  where  it  approaches 
the  stomach  near  the  cardiac  end  of  the  lesser  curvature.  A  catgut 
ligature  is  passed  around  the  gastric  artery  with  a  ligature  carrier 
and  tied.  The  pyloric  artery,  a  branch  of  the  hepatic,  is  also  tied 
near  the  pyloric  end  of  the  lesser  curvature.  An  opening  is  then 
made  in  the  gastro-colic  omentum  near  the  lower  border  of  the 
stomach,  and  through  this  opening  a  long  holding  forceps  with  bare 
hlades  is  introduced  and  applied  across  the  body  of  the  stomach, 
the  tip  of  the  forceps  reaching  up  beyond  the  lesser  curvature 
close  to  the  point  where  the  ligature  was  applied  to  the  gastric 
artery.  A  second  similar  holding  forceps  with  bare  blades  is  applied 
across  the  stomach  to  the  pyloric  side  of  this  first  forceps  and  also 
reaching  from  the  greater  to  the  lesser  curvature.  These  two 
forceps  are  applied  very  tightly.  The  left  gastro-epiploic  artery  is 
ligated  close  to  the  holding  forceps.  This  vessel  is  found  run- 
ning from  left  to  right  close  to  the  lower  border  of  the  stomach. 
The  stomach  is  divided  between  the  two  holding  forceps  and  then 
detached  along  its  greater  curvature,  working  toward  the  right  as 
far  as  the  pylorus.  The  gastro-colic  ligament  is  ligated  in  sections, 
■each  section  being  tied  double  and  the  ligatures  applied  sufficiently 
far  away  from  the  border  of  the  stomach  so  as  to  get  well  beyond 
any  diseased  Ij^mphatic  nodes  that  may  be  present.     If  there  are 


OPERATIONS  UPOX  THE  STOiL\CH. 


395 


Fig.  183. — Gastrectomy  (Hartmami).  Gastric  artery  has  been  tied  and  the 
gastrohepatic  ligament  divided.  The  stomach  has  been  divided  and  the  portion 
which  is  to  be  resected  with  the  clamp  still  applied  is  turned  over  toward  the 
right  side  in  order  to  facilitate  the  ligation  of  the  gastro-duodenal  artery.  A 
portion  of  the  peritoneum  has  been  removed  from  the  anterior  surface  of  the  head 
of  the  pancreas  in  order  to  expose  this  vessel,  which  has  been  picked  up  with 
the  blunt  ligature  carrier. 


396  .        ABDOMEN  AND  BACK. 

adhesions  to  the  transverse  mesocolon  the  operator  must  be  careful 
not  to  injure  the  arteria  colica  media  nor  to  include  it  in  a  ligature, 
because  this  vessel  supplies  the  transverse  colon,  and  its  occlusion 
would  result  in  gangreiie  of  this  part  of  the  bowel.  The  stomach 
having  been  thus  divided  and  separated  above,  along  the  lesser 
curvature  from  the  gastro-hepatic  ligament  and  below,  along  the 
greater  curvature  from  the  gastro-colic  ligament,  is  drawn  away 
over  toward  the  right  and  there  are  thus  exposed  the  posterior 
aspect  of  the  stomach  and  pylorus  and  the  head  of  the  pancreas, 
which  is  covered  by  the  parietal  layer  of  peritoneum  that  is  reflected 
upward  upon  the  posterior  abdominal  Avail.  The  gastro-duodenal 
arter}^  is  now  sought  for  and  ligated.  This  artery  is  a  branch  of 
the  hepatic  and  is  found  behind  the  p^dorus,  passing  downward 
between  the  head  of.  the  pancreas  and  the  second  part  of  the  duo- 
denum. It  is  necessary  to  tear  through  the  layer  of  peritoneum 
that  covers  the  anterior  surface  of  the  pancreas  in  order  to  secure 
the  vessel.  The  detachment  of  the  lymph-nodes  that  accompany 
this  vessel  and  its  main  branch,  the  gastro-epiploica  dextra,  and 
which  are  located  behind  and  below  the  pylorus,  is  accomplished 
without  much  difficulty  or  hemorrhage.  Two  straight  holding  for- 
ceps with  bare  blades  are  finally  applied  to  the  duodenum  and  the 
gut  divided  between  them,  and  thus  the  extirpation  of  the  diseased 
portion  of  the  stomach  is  accomplished. 

The  open  end  of  what  remains  of  the  stomach  is  closed  com- 
pletely with  a  line  of  suture  which  is  applied  before  the  forceps  is 
removed.  This  is  a  througli-and-through  suture  of  chromic  catgut 
and  is  applied  close  to  the  blades  (upon  their  proximal  side).  At 
every  fourth  or  fifth  puncture  of  the  needle  a  '^'TDack-stitch"  should 
be  made  in  order  to  prevent  the  suture  from  drawing  and  producing 
the  "puckering-string"  effect.  This  line  of  suture  serves  to  close 
the  opening  in  the  stomach  and  at  the  same  time  controls  the 
hemorrhage.  After  the  suture  has  been  introduced  the  forceps  is 
removed.  If  the  edge  of  the  stomach  beyond  the  line  of  the  suture 
is  too  broad  it  may  be  trimmed  off  with  the  scissors.  A  continuous 
Lembert  suture  of  silk  is  then  applied.  This  row  of  Lembert  suture 
takes  a  good,  broad  bite  in  the  wall  of  the  stomach  at  each  punc- 
ture, and  inverts  the  edges  and  completely  buries  the  first  through- 
and-through  catgut  suture. 

After  the  end  of  the  stomach  has  been  thus  closed  we  are 
ready  for  the   final   step    of   the   operation,   the    restoration   of   the 


Fig.  1S4.— Gastrectomy  (Mayo).  The  great  and  lesser  omenta  have  been  tied 
off  and  divided,  and  the  gastric  and  pyloric  arteries  ligated.  The  hand  is  passed 
down  behind  the  stomach  to  free  it  from  adhesions,  etc..  posteriorly.  Two  clamps 
have  been  applied  to  the  duodenum  preparatory  to  dividing  it.  The  blades  of 
the  distal  clamp  are  sheathed  with  rubber. 


398  ABDOMEN  AND  BACK. 

continuity  of  the  alinientai^  canal.  This  is  accomplished  either 
by  uniting  the  cut  end  of  the  duodenal  stump  to  a  new  opening 
which  is  made  in  the  posterior  wall  of  what  remains  of  the  stomach, 
gastro-duodenostomy  according  to  the  method  of  Kocher;  or  else  the 
end  of  the  stump  of  the  duodenum  is  closed  by  suture  and  a  communi- 
cation established  between  the  stomach  and  a  coil  of  the  jejunum — a 
gastro-jejunostomy.  The  choice  between  these  two  procedures  will 
depend  upon  the  mobility  and  length  of  the  stump  of  the  duodenum, 
the  preference  being  given  to  the  gastro-duodenostomy. 

If  a  gastro-duodenostomy  is  decided  upon,  this  is  established 
by  sewing  the  end  of  the  stump  of  the  duodenum  into  an  opening 
made  for  the  purpose  in  the  posterior  wall  of  the  stomach  according 
to  the  method  of  Kocher,  for  details  of  which  see  page  391. 

If  the  conditions  are  unfavorable  to  the  performance  of  the 
gastro-duodenostomj^,  if  the  stump  of  the  duodenum  is  too  short  and 
cannot  be  brought  up  into  apposition  with  the  stomach,  the  end  of  the 
duodenum  is  closed  in  a  manner  similar  to  that  employed  in  closing 
the  end  of  the  stomach  and  the  continuity  of  the  alimentary  canal 
restored  by  making  a  posterior  gastro-jejunostomy.     (See  Fig.  186). 

Mayo's  Method  of  Gastrectomy. — Eemoval  of  the  pylorus  and 
a  considerable  part  of  the  body  of  the  stomach — all  of  the  lesser  curva- 
ture and  the  greater  curvature  up  to  a  point  well  beyond  the  limits  of 
the  disease.    For  malignant  disease  of  the  pylorus. 

The  incision  is  made  in  the  linea  alba,  or  preferably  a  little  to  the 
left  of  the  middle  line,  reaching  from  the  ensiform  cartilage  downward 
to  the  umbilicus  or  beyond  that  point  if  necessary. 

The  left  lobe  of  the  liver  is  lifted  by  the  assistant  and  the  stomach 
pulled  firmly  downward  and  toward  the  right.  The  vessels  that  supply 
the  stomach  are  ligated  double  and  divided  between  the  ligatures.  The 
gastric  artery  is  tied  first;  the  finger  is  thrust  through  the  gastro- 
hepatic  ligament  and  the  vessel  secured  near  the  cardiac  end  of  the 
lesser  curvature.  The  ligature  is  applied  double  and  the  vessel  divided 
between  the  two  ligatures.  The  pyloric  artery,  which  is  a  branch  of  the 
hepatic,  is  next  secured,  tied  double,  and  divided;  it  is  found  near  the 
pyloric  end  of  the  lesser  curvature.  Between  these  two  points  the 
lesser  omentum,  gastro-hepatic  ligament,  is  tied  off  in  several  sections ; 
each  section  is  tied  double  and  divided  betvt^een  the  ligatures.  The 
ligatures  are  applied  sufficiently  far  away  from  the  lesser  curvature 
to  permit  enlarged  diseased  lymph-nodes  to  remain  attached  to  the 
stomach.    The  lesser  curvature  of  the  stomach  is  thus  detached  along 


OPERATIONS  UPON  THE  ST0:MACH.  399 

its  entire  length.  The  fingers  are  passed  through  the  opening  in  the 
lesser  omentum  clown  behind  the  stomach,  separating  adhesions  that 
fix  the  stomach  posteriorly.  Two  pair  of  narrow  straight  forceps  are 
applied  to  the  duodenum  well  below  the  limits  of  the  disease.  The 
first  is  a  holding  forceps  with  bare  blades  and  as  a  rule  is  placed 
about  one  inch  away  from  the  pylorus.  The  second  is  an  elastic- 
bladed  forceps,  the  blades  sheathed  with  rubber  tubing,  and  is  placed 
about  one  inch  distant  from  the  first.  The  duodenum  is  divided 
between  -the  two  forceps,  nearer  to  the  one  with  the  bare  blades. 
Enlarged  hnnph-nodes  lying  in  the  omentum  near  the  lower  border 
of  the  pylorus  are  carefully  separated  so  as  to  remain  attached  to  the 
pylorus  and  all  bleeding  points  clamped  and  ligated.  The  pyloric 
portion  of  the  stomach  in  the  grasp  of  the  bare-bladed  forceps  is  lifted 
up,  away  from  the  pancreas  and  the  arteria  gastro-duodenalis  as  it  lies 
in  the  space  between  the  head  of  the  pancreas  and  the  duodenum  is 
secured,  tied  double  and  divided  between  the  ligatures.  The  gastro- 
colic ligament  (omentum)  is  tied  off  in  several  sections,  each  ligature 
being  applied  double  and  cutting  between  and  working  along  the  lower 
border  of  the  stomach  from  the  pylorus  toward  the  left  as  far  as  the 
point  where  it  is  intended  to  divide  the  stomach.  These  ligatures  are 
applied  well  below  any  enlarged  lymph-nodes  so  that  when  the  tissue 
is  divided  between  the  ligatures  the  diseased  nodes  remain  in  con- 
nection with  the  stomach.  Care  must  be  exercised  to  avoid  the  arteria 
coliea  media  when  applying  the  ligatures  to  the  gastro-colic  ligament. 
This  vessel  is  the  sole  medium  of  supply  to  the  transverse  colon  in  many 
cases,  and  if  occluded  gangrene  of  this  part  of  the  bowel  would  result. 
Corresponding  to  the  point  on  the  lower  border  of  the  stomach 
where  it  is  proposed  to  divide  the  stomach,  the  arteria  gastro-epi- 
ploica  sinistra  is  secured  and  ligated.  In  this  way  the  entire  blood- 
supply  of  the  portion  of  the  stomach  which  is  to  be  removed  is  cut 
off.  Two  long-bladed  clamps  are  applied  across  the  body  of  the 
stomach  about  one  inch  back  of  the  intended  line  of  section  and, 
reaching  from  the  greater  curvature  up  to  the  lesser  curvature,  close 
to  the  point  where  the  gastric  artery  was  ligated.  Of  these  two 
clamps  the  one  nearer  the  diseased  area  is  a  holding  clamp  with  bare 
blades,  the  other  an  elastic-bladed  holding  clamp,  the  blades  sheathed 
with  rubber  tubing.  The  clamps  are  placed  parallel  to  each  other 
and  about  one  inch  apart.  The  tip  of  the  rubber-sheathed  clamp 
reaches  well  up  to  the  stump  of  the  gastric  artery.  The  stomach  is 
divided  close  to  the  bare-bladed  clamp,  leaving  a  margin  of  the 
stump  of  the  stomach  about  one  inch  broad  protruding  between  the 


400  ABDOMEN  AND  BACK. 

blades  of  tlie  rubber-sheatlied  clamp.  The  diseased  portion  of  the 
stomachy  together  with  the  diseased  lymph-nodes^  fat,  etc.,  still  con- 
nected with  it,  is  thus  resected  in  one  mass. 

The  end  of  the  stomach  is  closed  with  a  continuous  suture  of 
chromic  catgut.  Commencing  at  the  greater  curvature  and  working 
upward  toward  the  lesser  curvature  this  suture  is  applied  with  a 
straight  needle.  Any  portion  of  the  suture  line  which  tends  to  ooze  or 
which  is  not  satisfactorily  closed  should  be  secured  with  one  or  more 
additional  sutures.  A  second  line  of  suture,  continuous,  non-penetrat- 
ing Lembert  suture  of  linen  or  silk,  buries  the  first  line  of  suture, 
inverting  the  cut  edges  of  the  stomach  and  accurately  apposing  the 
serous  margins. 

After  the  stomach  has  been  closed  the  continuity  of  the  gastro- 
intestinal canal  is  re-established  either  according  to  the  method  of 
Kocher,  implanting  the  end  of  the  duodenum  into  an  opening  which 
is  made  for  the  purpose  in  the  lower  part  of  the  posterior  wall  of  the 
stomach ;  or  else  the  end  of  the  duodenal  stump  is  closed  in  a  manner 
similar  to  that  described  for  the  stump  of  the  stomach  and  a  posterior 
gastro-jejunostomy  without  a  loop,  made  according  to  the  second 
method  of  Billroth. 

The  stumps  of  the  gastro-colic  omentum  are  brought  together  with 
several  catgut  sutures.  If  the  stomach  tends  to  sag  it  may  be  anchored 
to  the  parietal  peritoneum,  to  the  left  edge  of  the  incision,  with  several 
chromic  catgut  sutures. 

Complete  Gastrectomy. — ^Extirpation  of  the  entire  stomach. 
First  case  by  Schlatter,  1897.  A  healthy  heart  is  essential  to  the 
success  of  this  operation.  The  operating  room  should  be  kept  warm 
and  the  patient  dressed  in  flannel  garments  to  prevent  as  much 
as  possible  loss  of  body  heat  by  radiation.  The  stomach  should  be 
washed  out  immediately  before  the  operation  is  commenced,  after 
the  patient  has  been  angesthetized. 

The  incision  is  best  made  in  the  linea  alba,  and  must  be  liberal, 
— from  six  to  seven  inches  in  length, — reaching  from  the  ensiform 
process  to  the  umbilicus  or  even  beyond  this  point. 

After  the  abdomen  has  been  opened  the  stomach  is  recognized 
and  examined,  and  search  made  for  secondary  deposits  in  the  liver, 
pancreas,  and  adjoining  lymphatic  glands. 

The  first  step  consists  in  the  isolation  of  the  stomach,  detach- 
ing it  from  the  greater  and  lessor  omenta  and  from  its  attachment 
to  the  spleen:    gastro-splenic  omentum.     In  many  cases  the  stomach 


OPERATIONS  UPON  THE  STOMACH. 


401 


Fig.  1S5.— Gastrectomy  (Mayo).  Diseased  portion  of  stomach  has  been  excised. 
The  end  of  the  stump  of  the  stomach  has  been  partly  closd  by  suture.  Blades  of 
the  clamps  sheathed  with  rubber. 


402 


ABDOMEN  AND  BACK. 


can  be  drawn  almost  entirely  out  of  the  abdomen  and  under  these 
conditions  the  performance  of  the  operation  is  greatly  facilitated. 
Commencing  at  the  pyloric  end  of  the  stomachy  the  omenta 
are  tied  off  in  sections, — first  the  lesser  and  then  the  greater  omen- 
tum,-— each  section  including  about  one  and  one-half  inches  of  the 
omentum  and  being  tied  double,  so  that  the  latter  can  be  divided 
between   the   ligatures.      In   ligating   the   lesser  omentum   the   liver 


%my 


Fig.  186. — Gastrectomy  (Mayo).  The  ends  of  the  stumps  of  the  stomach 
and  duodenum  have  been  closed  by  suture.  Dotted  lines  indicate  the  method 
of  restoring  the  gastro-intestinal  canal  by  Billroth's  second  method,  posterior 
gastro-jejunostomy. 

must  be  drawn  up  out  of  the  way  and  the  stomach  pulled  down. 
The  presence  of  the  common  bile-duct,  etc.,  between  the  layers  of 
the  lesser  omentum,  near  its  free  right  border,  should  not  be  for- 
gotten. The  ligatures  are  passed  with  the  blunt  ligature  carrier. 
After  the  lesser  and  greater  omenta  have  been  ligated  as  far  as  the 
middle  of  the  stomach  and  have  been  divided,  the  section  may  be 
made  between  the  pylorus  and  duodenum,  in  order  that  the  stomach 
may  the  better  be  drawn  down,  so  as  to  make  the  detacliment  of 
its  cardiac  end  less  difficult;  or  else  one  may  wait  until  the  whole 


OPERATIONS  UPON  THE  STOMACH.  403 

length  of  the  lesser  ami  greater  omenta  has  been  ligated  and  cut 
away  from  the  stomach  before  this  division  is  made. 

The  omentum  is  divided  between  the  double  ligatures  with 
the  scissors,  cutting,  piece  l)y  piece,  from  one  ligature  hole  into  the 
next.  The  main  arterial  branches  that  supply  the  stomach  should 
be  secured  and  ligated.  Above,  corresponding  to  the  lesser  curva- 
ture, the  pyloric  and  gastric.  Behind  the  pylorus  the  gastro-duo- 
denalis,  from  which  the  gastro-epiploica  dextra  is  derived,  is  sought 
for  and  ligated.  Corresponding  to  the  cardiac  end  of  the  stomach, 
passing  forward  in  the  gastro-splenic  omentum  to  reach  the  stom- 
ach, is  the  gastro-epiploica  sinistra.  This  branch  is  derived  from 
the  splenic  and  is  included  in  the  ligature  that  secures  the  gastro- 
splenic  omentum. 

After  the  stomach  has  been  detached  from  its  omenta  along 
the  lesser  and  greater  curvatures,  and  the  arteries  that  supply  the 
stomach  secured  and  ligated,  we  are  ready  for  the  next  step  of  the 
operation :  the  excision  of  the  stomach.  The  stomach  is  divided 
first  at  its  pyloric  end,  if  tliis  has  not  already  been  done.  A  rubber- 
sheathed  holding  clamp  is  placed  about  the  duodenum,  about  one 
and  one-half  inches  from  the  pylorus,  and  a  clamp  with  bare  blades 
about  the  pyloric  end  of  the  stomach,  and  between  these  the  intes- 
tine is  divided  with  the  scissors.  Any  escaping  contents  are  caught 
upon  a  gauze  pad,  and  the  end  of  the  duodenum,  sterilized  and 
wrapped  in  gauze,  and  with  the  compressor  still  applied,  is  dropped 
back,  temporarily,  into  the  abdomen. 

A  ligature  is  thrown  around  the  gastro-splenic  omentum;  this 
is  the  peritoneal  fold  that  reaches  from  the  fundus  of  the  stomach 
to  the  spleen,  and  through  it  the  vasa  brevia  pass  to  the  stomach. 
This  ligature  is  applied  double  so  that  we  may  divide  between  the 
two.  Special  pains  should  be  taken  to  secure  the  vessels  in  the 
gastro-splenic  omentum,  leaving  the  ligature  long  that  the  pedicle 
may  be  drawn  forward,  so  that,  if  necessary,  the  individual  vessels 
may  be  secured  with  additional  ligatures. 

To  reach  the  oesophagus  the  stomach  must  be  pulled  well  down- 
ward. A  rubber-sheathed  holding  clamp  is  placed  about  the  oesoph- 
agus a  short  distance  below  the  diaphragiu,  and  a  clamp  with  bare 
blades  about  the  oesophageal  end  of  the  stomach,  and  between  these 
the  oesophagus  is  divided  with  the  scissors.  The  stomach  is  thus 
removed. 

After  the  stomach  has  been  excised  it  becomes  necessary  to 
restore  the  continuity  of  the  alimentary  canal,  either  by  joining  the 


404 


ABDOMEN  AND  BACK. 


end  of  tlie  duodermm  to  the  end  of  the  oesophagus,  oesophago-duo- 
denostomy,  or  else  by  inserting  the  end  of  the  oesophagus  into  the 
je]\inum,  cesophago-jejunostomy. 


Fig.  187.— Gastrectomy.  OES,  stump  of  (BSophagus;  D,  end  of  the  duo- 
denum. Dotted  lines  indicate  the  excised  stomach.  The  small  intestine  (jeju- 
num) has  been  drawn  up  into  apposition  with  the  stump  of  the  oesophagus,  as 
in  cesophago-jejunostomy. 

In  most  cases  the  oesophagus  can  be  drawn  down  and  the  duo- 
denum sufficiently  mobilized  to  allow  of  its  being  brought  up  into 
apposition  with  the  end  of  the  oesophagus  without  undue  tension. 
In  this  case  the  parts  may  be  joined  together  with  a  Murphy  button 


OPERATIONS  UPON  THE  STOiLiCH.  405 

or  else  they  may  be  sutured,  eud-to-eud  (see  ''End-to-End  Anasto- 
mosis"). If  the  button  is  used  for  the  purpose  of  restoring  the 
continuity  of  the  alimentary  canal,  then,  after  it  has  been  inserted 
and  the  compression  clamps  removed  from  the  duodenum  and 
oesophagus,  a  row  of  outside  Lembert  sutures  should  be  applied  to 
make  the  junction  still  more  secure.  These  sutures  include  the 
serous  and  muscular  coats,  but  do  not  pass  through  the  mucous 
membrane.  If  unable  to  approximate  the  parts  as  described,  the 
end  of  the  duodenum  may  be  inverted  and  closed  with  a  double  row 
of  sutures  and  an  oesophago-jejunostomy  done,  the '  end  of  the 
oesophagus  being  sutured  into  an  opening  which  is  made  in  the 
small  intestine.  The  upper  portion  of  the  jejunum  is  sought  in 
the  upper  back  part  of  the  abdominal  cavity, — to  the  left  of  the 
body  of  the  second  lumbar  vertebra, — and  a  coil  of  gtit  about 
eighteen  inches  beyond  this  point  selected.  A  segment  of  this  coil 
of  gut  about  eight  inches  long  is  tied  oif  with  tapes;  first  one  tape 
is  tied  about  the  gut  and  then,  after  the  contents  of  the  segment 
have  been  stripped  along  with  the  fingers,  the  other  tape  is  tied. 
This  segment  of  gut  is  brought  up  in  front  of  the  transverse  colon, 
into  apposition  with  the  end  of  the  oesophagus.  The  posterior  half 
of  the  end  of  the  oesophagus  is  sutured  to  the  wall  of  the  coil  of 
gut  with  a  row  of  continuous  Lembert  sutures.  These  sutures 
secure  the  wall  of  the  oesophagus  about  one-fourth  inch  beyond  its 
«ut  edge,  and  include  the  serous  and  muscular  coats,  but  not  the 
mucous.  The  needle,  still  cariying  the  thread,  is  then  discarded 
temporarily,  and  an  incision  is  made  in  the  gut  corresponding  in 
length  to  the  size  to  the  end  of  the  oesophagus.  The  edge  of 
this  opening  in  the  gut  is  sutured  to  the  end  of  the  oesophagus 
all  around  Avith  a  continuous  stitch  of  chromic  catgut  that  includes 
all  the  layers.  When  this  suture  has  been  completed  and  the  end 
of  the  oesophagus  thus  securely  fixed  to  the  opening  in  the  intestine, 
the  first  needle,  that  with  which  the  posterior  half  of  the  end  of 
the  oesophag-us  was  joined  to  the  gut,  is  again  taken  in  hand  and 
the  anterior  half  of  the  ''outside  serous  ring"  suture  applied.  The 
abdominal  wound  is  closed  without  drainage.  It  is  advisable,  in 
addition,  to  establish  an  entero-anastomosis  between  the  most  de- 
pendent portions  of  the  two  limbs  of  the  attached  coil  of  gut  in 
order  to  insure  the  ready  escape  of  the  bile  and  pancreatic  juice  from 
the  proximal  into  the  distal  arm  of  the  gut. 

During  the   course   of   the  operation   the   solar   plexus   may   be 
considerably    molested,    and    at    the    time    that    the    oesophagus    is 


406  ABDOMEN  AND  BACK. 

severed  both  pneumogastric  nerves  are  also  divided.  The  shock  is 
therefore  apt  to  be  marked,  and  should  be  counteracted  by  avoiding 
as  much  as  possible  loss  of  body  heat  during  the  operation  and  by 
administering  proper  stimulation.  The  division  of  the  pneumo- 
gastrics  leads  to  disturbance  of  the  heart's  action;  it  becomes  very 
greatly  accelerated.  An  attempt  should  be  made  to  regulate  this, 
probably  with  proper  doses  of  digitalis  hypodermically.  For  the 
first  few  days  the  patient  is  nourished  per  rectum;  after  forty- 
eight  hours  fluids  may  be  given  per  mouth,  first  small  quantities 
of  water  and'  then  In'oth,  milk,  etc.,  may  be  added.  At  the  end  of 
a  week  a  moderate  amount  of  solid  food  may  be  taken  through  the 
mouth. 

THE  SMALL  INTESTINE. 

The  Surgical  Anatomy  of  the  Small  Intestine.  The  Duodenum 
is  the  first  part  of  the  small  intestine.  It  is  about  ten  inches  long 
and  commences  at  the  pyloric  end  of  the  stomach  and  ends  at  the 
jejunum.  Its  wall  is  moderately  thick.  It  is  usually  described  as 
consisting  of  three  parts. 

The  first,  or  ascending,  part  is  freely  movable,  continuous  with 
the  pylorus,  and  entirely  invested  by  peritoneum.  It  passes  from  the 
pyloric  end  of  the  stomach  upward  and  backward  toward  the  right  as 
high  as  the  level  of  the  twelfth  dorsal  vertebra ;  it  reaches  close  to  the 
under  surface  of  the  liver,  with  which  it  is  connected  by  the  so-called 
ligamentum  hepatico-duodenale.  This  ligament  is  simply  the  free^ 
thickened,  right  edge  of  the  lesser  omentum;  ligamentum  gastro- 
hepaticum.  Between  the  layers  of  the  lesser  omentum  are  the  hepatic 
artery,  portal  vem,  and  common  bile-duct,  the  artery  ascending  to  the 
liver,  and  the  duct  and  vein  descending  behind  this  first  part  of  the 
duodenum.  Between  the  layers  of  the  lesser  omentum  the  artery  lies 
to  the  left,  the  duct  to  the  right,  and  the  vein  between  and  behind  both. 

The  duodenum  then  makes  a  turn  downward  along  the  right 
side  of  the  first  and  second  lumbar  vertebrae,  lying  upon  the  front  of 
the  right  kidney,  with  the  head  of  the  pancreas  to  the  left  {i.e.,  internal 
to  this  part  of  the  duodenum).  This  is  called  the  second  part  of  the 
duodenum.  It  differs  from  the  first  part  in  being  fixed  to  the  posterior 
wall  of  the  abdomen  and  in  not  being  completely  surrounded  by 
peritoneum,  but  simply  covered  by  the  peritoneum  upon  its  front 
surface,  and  therefore  when  we  look  for  this  part  of  the  duodenum, 
after  reflecting  the  transverse  colon  and  the  great  omentum  upward,  it 
is  not  to  be  seen,  and  is  only  exposed  to  view  after  the  peritoneum. 


SURGICAL  ANATOMY  OF  THE  SMALL  INTESTINE.  407 

which  covers  its  anterior  surface  has  been  nit  tlirough.  The  common 
bile-duct  and  the  pancreatic  duct  open  into  the  second  part  of  the 
duodenum,  adjacent  to  the  head  of  the  pancreas.  These  ducts  pass 
obliquely  thi'ough  tlio  wall  of  tlie  diu)(h>num,  and  join  with  each  other, 
before  entering  the  gut  through  a  single  eonnnon  orifice,  which  is  found 
upon  the  inner  wall  of  tbe  duodenum  in  tlie  center  of  a  papilla.  A 
probe  maybe  passed  fi'oni  tbis  ])art  of  the  duodenum  into  the  common 
duct  or  into  the  pancreatic  duct.  Between  the  head  of  the  pancreas 
and  the  second  part  of  the  duodenum  in  the  injected  cadaver  there  may 
be  seen  the  anastomosis  between  the  superior  and  inferior  pancreatico- 
duodenal is  arteries:  branches  derived  from  the  hepatic  and  superior 
mesenteric,  respectively. 

At  the  level  of  the  third  lumbar  vertebra  the  duodenum  makes 
another  turn,  passing  across  the  body  of  the  third  lumbar  from  the 
right  to  the  left  side  of  this  vertebra,  and  at  the  same  time  ascend- 
ing to  the  level  of  the  second  lumbar  vertebra.  This  is  known  as  the 
third  part  of  the  duodenum.  The  aorta,  etc.,  lie  behind  this  part  of 
the  duodenum,  and  the  head  of  the  pancreas  is  situated  above  it. 

Upon  the  left  side  of  the  Ijody  of  the  second  lumbar  vertebra  the 
duodenum  is  fixed  to  the  vertebral  column  by  a  thickened  portion  of 
peritoneum ;  this  fold  contains  some  unstriped  muscular  fibers,  and 
is  called  the  suspensory  ligament  of  the  duodenum,  the  ligament  of 
Treitz.  This  third  part  of  the  duodenum  also  is  covered  only  upon 
its  anterior  surface  by  the  peritoneum,  and  is  fixed  in  the  back  of 
the  abdomen,  in  common  with  the  pancreas,  by  this  layer.  This 
portion  of  the  duodenum  is  not  to  be  seen  until  after  the  layer  of 
peritoneum  which  covers  its  anterior  surface  and  conceals  it  from  view 
has  been  torn  through.  The  whole  duodenum  is  curved  like  a  horse- 
shoe, in  the  hollow  of  which  the  head  of  the  pancreas  is  received. 

The  Jejunum  and  Ileum,  about  twenty  feet  long,  make  up 
the  rest  of  the  tul)e  of  small  intestine,  and  are  the  direct  continua- 
tion of  the  duodenum,  terminating  in  the  caecum  in  the  right  iliac 
fossa.  Upon  the  left  side  of  the  second  lumbar  vertebra,  where  the 
duodenum  ends  and  the  jejunum  l^egins,  the  intestinal  canal  becomes 
again  provided  with  a  complete  peritoneal  investment  and  a  long 
mesentery. 

The  jejunum  forms  about  two-fifths  of  the  lengih  of  the  small 
intestine  and  becomes  the  ileum  where  the  valvules  conniventes,  which 
characterize  its  inner  surface,  cease  to  exist.  It  is  thick  walled  and 
large  in  calibre,  and  therefore  resembles  somewhat  the  large  intestine ; 


408  ABDOMEN  AND  BACK. 

still,  it  is  readily  distinguished  from  this  part  of  the  gut  by  the 
absence  of  the  longitudinal  strige  and  appendices  epiploicse  and  in  not 
being  sacculated. 

At  its  commencement,  upon  the  left  side  of  the  second  lumbar 
vertebra,  the  jejunum  seems  to  project  directly  forward,  through  the 
parietal  peritoneum  which  lines  the  back  of  the  abdominal  cavity. 
This  appearance  is  due  to  the  fact  that  the  portion  of  the  gut, 
duodenum,  which  immediately  precedes  the  jejunum,  is  not  provided 
with  a  mesentery ;  it  lies  behind  the  peritoneum  and  is  covered  by  it 
upon  its  anterior  surface  only,  whereas  the  commencement  of  the 
jejunum  and  the  rest  of  the  small  intestine  are  provided  with  an 
investment  of  peritoneum,  which  completely  surrounds  them,  and  a 
mesentery,  which  suspends  them  to  the  back  of  the  abdomen,  and,  there- 
fore, where  this  arrangement  commences,  the  gut  appears  to  project 
directly  forward  through  the  peritoneum  from  the  posterior  wall  of  the 
abdomen.  The  process  of  peritoneum  that  incloses  the  first  part  of 
the  jejunum  marks  the  commencement  of  the  mesentery.  The  first 
portion  of  the  jejunum  lies  in  close  relation  with  the  posterior  wall 
of  the  stomach.  We  can  locate  it  by  reflecting  the  great  omentum, 
and  with  it  the  transverse  colon,  upward  out  of  the  way,  and  then, 
passing  the  hand  backward,  along  the  under  surface  of  the  transverse 
mesocolon  to  the  vertebral  column,  this  coil  of  intestine  is  found  lying 
just  to  the  left  of  tbe  body  of  the  second  lumbar  vertebra.  An  attempt 
to  draw  this  coil  of  gut  out  of  the  abdomen  will  show  that  it  is  fixed 
within  the  abdomen  and  this  fact  will  serve  to  identify  it  positively. 

The  ileum,  which  is  the  continuation  of  the  jejunum,  constitutes 
three-fifths  of  the  length  of  the  small  intestine.  It  becomes  progres- 
sively smaller  in  calibre  and  thinner  as  we  trace  it  toward  its  termina- 
tion at  the  caecum,  where  its  wall  is  thinnest  and  its  calibre  narrowest. 

The  jejunum  and  ileum  are  suspended  free  in  the  abdominal 
cavity  arranged  coil  upon  coil,  and  are  provided  with  a  complete 
peritoneal  envelope  and  a  long  mesentery  by  which  they  are  attached 
to  the  vertebral  column  in  the  back  of  the  abdomen. 

The  Mesenteey  is  a  reflection  of  peritoneum  containing  some^ 
unstriped  muscular  fiber,  fat,  etc. ;  it  serves  to  suspend  the  gut  in  the 
abdomen  and  at  the  same  time  supports  the  blood-vessels,  lymphatics, 
nerves,  etc.,  in  their  course  to  and  from  the  small  intestine. 

The  mesentery  is  fan-shaped.  The  distal  border  is  very  long, 
corresponding  to  the  whole  length  of  the  small  intestine  to  which 
it  is  attached ;  the  proximal  border  is  short  and  is  fixed  to  the  anterior 
surface  of  the  vertebral  column,  reaching  from  the  left  side  of  the 


SURGICAL  ANATOMY  OF  THE  SMALL  INTESTINE. 


409 


Fig.  188. — Section    of    Intestine    and   its    Mesentery  to    show    Separation    of    its 
Layers  and   the   "Dead   Space." 


"j^im 


Fig.  189. — Blood-supply   of  Small    Intestine.     Absence   of   free   anastomosis 
between  the  ultimate  vessels  may  be  noted. 


4,10  ABDOMEN  AND  BACK. 

second  lumbar  vertebra^  where  the  duodenum  ends  and  the  jejunum 
commences,  downward,  to  the  right  side  of  the  fifth  lumbar  vertebra; 
its  line  of  attachment  is  thus  oblique  from  the  left  side,  above,  down- 
ward and  to  the  right.  The  vertebral  ledge  of  the  mesentery  is  but 
six  inches  long,  whereas  the  distal,  intestinal  edge  is  about  twenty 
feet  long,  and  in  order  to  accommodate  these  two  borders  to  each 
other  the  intestinal  end  of  the  mesentery  is  folded  and  folded  upon 
itself,  making  a  series  of  plaits. 

Where  the  two  layers  of  peritoneum  of  which  the  mesentery  is 
composed  meet  the  intestine,  they  diverge  and  surround  the  intestine 
in  a  sling-like  fashion,  the  intestine  being  entirely  invested  except  for 
the  small  "dead  space"  which  corresponds  to  the  separation  of  the 
layers  of  the  mesenter}^  at  the  so-called  mesenteric  border  of  the 
intestine.  Here  the  mesentery  is  not  applied  directly  to  the  surface 
of  the  intestine,  but  is  sej^arated  from  it,  leaving  a  small  space — "dead 
space"— where  the  serous  layer  does  not  form  part  of  the  wall  of  the 
intestinal  tube. 

The  Blood-supply  of  the  Small  Intestine  is  furnished  by 
the  superior  mesenteric  artery.  This  vessel  is  given  off  from  the 
anterior  aspect  of  the  aorta,  and  passes  forward  between  the  lower 
border  of  the  pancreas  and  third  part  of  the  duodenum;  it  is  located 
between  the  layers  of  the  mesentery,  and  courses,  in  a  curved  direction 
downward  and  to  the  right,  toward  the  right  iliac  fossa.  The  superior 
mesenteric  is  a  short,  thick  trunk.  From  its  convex  side  it  gives  oE 
branches  to  supply  the  whole  lengih  of  the  small  intestine;  from  its 
concave  side  it  gives  off  branches  to  the  large  intestine,  to  the  caecum 
and  vermiform  appendix,  ascending  colon,  and  transverse  colon,  finally 
anastomosing  with  a  branch  from  the  inferior  mesenteric  (see  below). 
The  superior  mesenteric  vein  accompanies  the  artery  and  its  branches, 
and  behind  the  pancreas  joins  with  the  splenic  to  form  the  portal  vein. 
The  blood  in  the  portal  vein  is  derived  from  the  intestine;  before 
reaching  the  general  circulation  it  passes  through  the  liver;  it  leaves 
the  liver  through  the  hepatic  veins,  two  or  three  in  number,  which 
empty  into  the  inferior  vena  cava. 

The  branches  of  the  superior  mesenteric,  which  supply  the  small 
intestine,  are  given  off,  as  already  mentioned^  from  the  convex,  left, 
side  of  the  artery.  These  branches  do  not  pass  direct  to  the  intestine, 
but  anastomose  with  each  other,  forming  a  series  of  arches.  From 
this  set  of  arches  another  series  of  branches  is  given  off,  and  thus  this 
peculiar  anastomotic  arch  formation  continues  until  the  intestine  is 
almost  reached;    finally  the  individual  branches  from   the  ultimate 


OPERATIONS  UPOX  THE  SMALL  INTESTINE.  411 

arches  are  distributed  to  the  wall  of  the  intestine.  They  pass  to  the 
intestine  from  between  the  layers  of  the  mesentery,  where  these 
separate  to  envelop  the  intestine — that  is,  at  the  mesenteric  border — 
through  the  so-called  "dead  space."  After  the  ultimate  vascular 
branches  reach  the  wall  of  the  gut  they  do  not  communicate  freely  with 
each  other;  therefore  each  segment  of  gut  is  dependent  almost 
exclusively  upon  one  or  two  definite  vessels  for  its  nutrition  and 
integrity.  The  same  arrangement  holds  good  for  the  ultimate  veins. 
If  several  of  these  ultimate  vascular  branches  are  severed  close  to  the 
gut  or  become  emholized  or  thrombosed,  we  are  apt  to  have,  as  a  result, 
gangrene  of  the  corresponding  segment  of  the  gut.  Wounds  of  the 
intestine  at  the  mesenteric  border  are  unfavorable  for  suture  on  account 
of  the  absence  of  the  serous,  peritoneal  covering,  at  this  part.  Wounds 
at  the  mesenteric  border  of  the  gait  almost  of  necessity  include  division 
of  the  ultimate  intestinal  arteries  and  veins,  and  therefore  interfere 
seriously  with  the  blood-supply  to  the  corresponding  part  of  the  gut. 

OPERATIONS  UPON  THE  SMALL  INTESTINE. 

Enterotomy. — Incision  into  the  small  intestine.  For  the  removal 
of  foreign  bodies  from  the  intestine.  The  operation  may  also  Ije  done 
during  the  course  of  laparotomy  for  acute  intestinal  obstruction,  after 
the  obstruction  has  ])een  relieved,  for  the  purpose  of  emptying  the 
bowel  above  the  point  where  it  was  obstructed ;  or  the  operation  may 
be  deliberately  undertaken  with  the  object  of  relieving  the  bowel  of 
its  poisonous  contents  in  advanced  cases  of  acute  peritonitis.  In 
cases  of  acute  peritonitis  the  contents  of  the  distended  paralyzed 
bowel  are  oftentimes  excessively  poisonous  and  are  the  chief  source 
of  the  toxins  that  endanger  the  patient's  life. 

A  coil  of  gut  is  selected  and  constricted  with  a  piece  of  narrow 
tape.  The  coil  of  gut  is  then  emptied  by  stripping  between  the 
fingers  and  a  second  piece  of  tape  passed  around  the  gut  and  tied;  or 
rubber-sheathed  holding  clamps  may  be  used  to  compress  the  gut. 
The  coil  of  gut  which  has  thus  been  emptied  is  incised.  According 
to  the  plan  of  Moynihan  a  long,  straight,  glass  tulje  with  a  length  of 
rubber  tubing  attached  to  one  end  is  introduced  through  the  incision 
in  the  bowel,  and  after  the  constricting  tapes  or  clamps  are  removed 
the  glass  tube  is  pushed  gently  onward  into  the  gut,  at  the  same  time 
drawing  the  gut  over  the  tube.  In  this  way  a  considerable  length  of 
the  bowel  may  l)e  reached  by  the  tube  and  emptied.  The  bowel  may 
be  flushed  with  salt  solution  by  puncturing  it  high  up  with  a  medium- 


413 


ABDOMEN  AND  BACK. 


sized  needle  with  tube  and  funnel  attached.  Abovd  the  place  of 
puncture  a  constricting  tape  or  clamp  is  placed  upon  the  gnt.  As 
the  water  runs  into  the  intestine  the  glass  tube  is  slowly  withdrawn, 
being  followed  down  by  the  stream  of  water,  which  enters  the  bowel 
through  the  needle  and  escapes  from  the  intestine  through  the  glass 
tube.  The  openings  in  the  bowel  are  closed  with  several  Lembert 
sutures  of  silk. 


;':;k  TRANSVERSALIS 
i\^yC     FASCIA 

'^PERITONEUM 


Fig.  190. — Enterostomy,  temporary.  The  wall  of  the  gut  has  been  sutured 
all  around  to  the  edges  of  the  peritoneum  and  fascia  transversalis  with  a  non- 
penetrating stitch.  A  purse-string  has  been  introduced  in  the  wall  of  the  intes- 
tine, which  has  been  incised  to  permit  introduction  of  a  tube. 


Enterostomy. — The  establishment  of  an  opening  into  the  small 
intsetine  for  the  purpose  of  providing  temporary  drainage  of  the 
intestinal  canal,  temporary  enterostomy,  or  may  be  for  the  purpose 
of  introducing  nutriment  in  cases  of  inoperable  malignant  disease 
of  the  stomach,  etc.,  permanent  enterostomy,  for  example,  "Jeju- 
nostomy.^^ 

Temporary  Enterostomy  is  resorted  to  in  cases  of  acute  septic 
peritonitis  with  distention  and  paralysis  of  the  bowel.  The  con- 
tents of  the  intestinal  canal  undergo  septic  changes  and  form  the 
chief  source  of  the  poisons  that  are  absorbed.  Striking  improve- 
ment will  often  be  observed  in  these  cases  after  irrigation  of  the 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  413 

Btomach  and  large  bowel — the  patients  are  relieved  of  at  least  a 
part  of  the  septic  material.  In  many  cases,  however,  these  meas- 
ures are  not  sufficient  to  eliminate  the  poisons,  and  direct  drainage 
is  provided  by  making  the  opening  into  the  intestinal  canal.  Some 
very  desperate  cases  of  acute  septic  peritonitis  may  be  saved  by  this 
means.  The  fistulous  opening  may  be  expected  to  close  spontane- 
ously in  many  cases  after  it  has  served  its  purpose. 

The  patients  are  often  in  collapse,  so  that  the  operation  must 
be  completed  promptly  and  usually  under  local  anaesthesia. 

The  incision  is  made  in  the  right  iliac  region.  An  incision 
similar  to  that  which  is  usually  made  for  appendicitis  is  employed. 
When  the  abdomen  is  opened  the  gut  may  be  found  adherent,  so 
that  it  cannot  be  drawn  out  of  the  incision.  Under  these  circum- 
stances the  distended  coil  of  intestine  is  fixed  to  the  edges  of  the 
parietal  peritoneum  and  fascia  transversalis.  The  lower  down, 
nearer  the  caecum,  the  coil  of  gait  which  is  secured,  the  better,  or 
the  caecum  itself  may  be  used  if  it  presents  in  the  incision.  The 
coil  of  gut  is  fixed  to  the  edges  of  the  peritoneum  and  fascia  trans- 
versalis, all  around,  with  a  continuous  suture  of  fine  silk  carried  in 
a  thin  curved  needle.  The  suture  does  not  penetrate  the  entire 
thickness  of  the  wall  of  the  bowel.  One  or  two  sutures  of  silk  are 
introduced  in  each  end  of  the  incision  and  penetrating  all  the  layers 
of  the  abdominal  wall,  including  the  peritoneum.  These  stitches 
are  introduced  before  the  gut  is  sutured  to  the  edges  of  the  peri- 
toneum, but  they  are  not  tied  until  after  this  succeeding  step  of 
the  operation  has  been  accomplished.  They  serve  to  close  the 
incision  for  part  of  its  extent.  A  small  opening  is  made  in  the 
bowel  with  a  narrow-bladed  knife.  When  the  bowel  is  opened  a 
rubber  tube  is  introduced  into  the  bowel  and  fixed  near  the  edge 
of  the  opening  with  a  chromic  catgut  suture.  The  edges  of  the 
opening  in  the  bowel  are  drawn  tightly  around  the  tube  with  a 
purse-string  suture  of  chromic  catgut,  which  is  introduced  before 
the  gut  is  incised.  By  this  means  the  discharge  from  the  bowel 
will  be  prevented  from  leaking  around  the  tube,  and  will  be  con- 
ducted away  from  the  incision  at  least  for  a  few  days  until  the  tube 
works  loose. 

The  edge  of  the  skin  are  covered  with  rubber  tissue,  and  the 
incision  packed  around  the  tube  with  iodoform  gauze.  It  is  desir- 
able to  delay  incising  the  bowel,  if  the  conditions  will  permit,  if 
only  for  a  period  of  twelve  hours,  in  order  to  allow  time  for  adhe- 
sions to  form  between  the  bowel  and  the  edges  of  the  peritoneum. 


414  ABDOMEN  AND  BACK. 

When  the  gut  is  not  adherent  and  can  be  drawn  out  of  the 
abdominal  incision,  it  may  be  opened  immediately  and  a  rubber 
tube  or  a  Paul  glass  tube  introduced.  A  coil  of  distended  gut 
is.  drawn  out  of  the  incision  and  emptied  of  its  contents  as  com- 
pletely as  possible  by  stripping  between  the  fingers,  and  two  rubber- 
sheathed  compressor  forceps  applied  or  two  pieces  of  narrow  tape 
tied  around  the  gut.  Gauze  compresses  are  placed  around  and  under 
the  coil  of  gut  to  protect  the  peritoneal  cavity.  A  small  incision 
is  made  in  the  bowel  and  the  tube  introduced,  and  the  edges  of  the 
opening  in  the  bowel  drawn  tight  around  the  tube  with  a  through-and- 
through  purse-string  suture  of  chromic  catgut.  The  purse-string 
suture  is  introduced  before  the  bowel  is  incised.  If  a  rubber  tube  is 
used  it  is  fixed  with  a  catgut  stitch  which  passes  through  it,  to  the 
edge  of  the  incision  in  the  gut.  The  compressor  forceps  or  tapes  are 
removed  from  the  gut  and  a  clamp  placed  temporarily  upon  the  end 
of  the  rubber  tube  to  prevent  escape  of  intestinal  contents  during 
the  final  steps  of  the  operation.  The  gut  is  fixed  to  the  edges  of  the 
abdominal  incision  with  two  or  more  sutures  of  chromic  catgut. 
These  sutures  pick  up  the  wall  of  the  gut  a  short  distance  above 
and  a  short  distance  below  the  place  where  the  tube  emerges.  They 
take  several  good  broad  bites  in  the  wall  of  the  gut  without  pene- 
trating and  catch  the  edges  of  the  peritoneum  and  transversalis 
fascia  on  either  side  of  the  incision.  When  these  sutures  are  tied 
later  they  serve  to  suspend  the  coil  of  gut  and  fix  it  to  the  peritoneal 
edges  in  the  incision.  The  incision  is  closed  in  part  by  one  or  two 
through-and-through  sutures  of  fairly  heavy  silk  which  are  placed 
in  the  upper  and  in  the  lower  end  of  the  incision.  After  the  through- 
and-through  sutures  have  been  introduced  the  two  suspension  sutures 
of  catgut  that  secure  the  gut  are  tied  and  finally  the  through-and- 
through  sutures  are  tied. 

The  edges  of  the  skin  are  covered  by  rubber  tissue  and  the 
incision  packed  around  the  tube  with  iodoform  gauze. 

Permanent  Entebostomy  is  made,  usually,  for  the  purpose  of 
introducing  nutriment  in  cases  of  inoperable  cancer  of  the  pylorus,  etc. 
The  Maydl  operation  may  be  employed  or  the  fistulous  tract  may  be 
established  according  to  the  plan  of  Witzel,  as  described  in  gastros- 
tomy, by  infolding  a  rubber  catheter  in  the  serous  surface  of  the  wall 
of  the  intestine. 

Jejunostomt,  Maydl. — The  formation  of  a  jejunal  fistula  for 
the  purpose  of  feeding.    The  procedure  is  employed  in  those  cases  of 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


415 


inoperable  malignant  disease  of  the  pylorus  where  a  gastro-Jejunostomy 
cannot  be  made. 


B 


Fig.  191.— Jejunostomy  (Maijdl).  The  upper  segment  of  the  gut  has  been 
anastomosed  into  the  side  of  the  lower  segment.  The  end  of  the  latter  has 
been  fixed  in  the  incision  in  the  abdominal  wall  A-B.  The  arrows  indicate  direc- 
tion of  the  peristaltic  wave. 

The  abdomen  is  opened  by  an  incision  through  the  middle  of  the 
left  rectus,  reaching  upward  from  the  level  of  the  umbilicus  for  a 
distance  of  three  or  four  inches.  Through  this  incision  the  operator 
is  able  to  investigate  the  condition  of  the  stomach,  etc. 


416  ABDOMEN  AND  BACK. 

The  uppermost  portion  of  the  jejunum  is  sought  for  and  drawn 
out  of  the  incision.  This  part  of  the  gut  is  found  to  the  left  of  the 
body  of  the  second  lumbar  vertebra  and  may  be  identified  by  the  fact 
that  it  is  fixed  within  the  abdomen  and  resists  the  efl^ort  to  draw  it  out 
of  the  incision. 

A  loop  of  gut  about  20  cm.  distant  from  the  commencement  of  the 
jejunum  is  selected,  and,  after  it  has  been  stripped  between  the  fingers 
to  empty  it,  it  is  tied  off  with  two  pieces  of  narrow  tape  five  or  six 
inches  apart,  so  as  to  prevent  re-entrance  of  contents,  and  then  divided 
straight  across  with  the  scissors.  The  proximal  end  of  the  gut  which 
has  been  thus  divided  is  implanted  in  an  incision  which  is  made  in  the 
side  of  the  jejunum  about  20  cm.  still  farther  along,  nearer  the  caecum. 
This  coil  of  gut  is  also  emptied  by  stripping  between  the  fingers  and 
temporarily  occluded  by  tying  tapes  about  it  before  it  is  incised.-  The 
end  of  the  proximal  portion  of  the  gut  is  anastomosed  to  the  opening 
in  the  side  of  the  distal  portion  by  means  of  the  sutures  (see  "End-to- 
Side  Anastomosis'^).  After  the  anastomosis  has  been  effected  as  above 
described  the  distal,  free  end  of  the  divided  coil  is  drawn  through  a 
separate  small  opening  in  the  peritoneum,  transversalis  fascia  and 
rectus  muscle.  This  opening  is  made  alongside  of  the  lower  end  of 
the  first  incision.  The  end  of  gut  is  drawn  through  the  opening  which 
is  thus  made  and  then  under  the  integument  which  is  raised  with  the 
handle  of  the  scalpel  into  the  lower  end  of  the  first  incision,  and  is 
there  fixed  with  several  interrupted  chromic  catgut  sutures  to  the 
edges  of  the  skin.  These  sutures  pass  through  the  entire  thickness 
of  the  end  of  the  gut  and  fasten  it  securely  to  the  skin  in  the  lower 
end  of  the  incision.  The  original  incision  is  closed,  layer  by  layer, 
first  peritoneum  and  transversalis  fascia,  then  muscle,  then  apo- 
neurosis and  finally  skin  except  below  where  the  end  of  the  gut 
presents.  The  peristaltic  wave  runs  in  a  direction  away  from  the 
jejunostomy  opening  onward  toward  the  c^cum;  hence  there  is  but 
little  likelihood  of  escape  of  intestinal  contents. 

WiTZEL  Method. — The  loop  of  jejunum  is  drawn  out  of  the 
incision  in  the  abdomen  and  the  wall  folded  over  a  rubber  catheter  the 
end  of  which  pierces  the  gut  through  a  small  incision  in  a  manner 
similar  to  that  described  in  the  Witzel  method  of  gastrostomy.  The 
abdominal  incision  is  closed  except  at  the  place  where  the  catheter 
protrudes. 

Enterorrhaphy. — Suture  of  the  intestine  for  gunshot  and  stab 
wounds  and  for  perforations  due  to  ulceration,  typhoid,  chronic  duo- 
denal ulcer,  fistulas,  etc. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  417 

For  Gunshot  and  Stab  Wounds. — These  injuries  are  usually 
accompanied  by  hemorrhage  from  wounded  vessels  in  the  mesentery. 
The  several  vessels  should  be  ligated  with  catgut.  If  large,  and 
especially  if  divided  close  to  the  gnit,  it  is  well,  after  ligating  the 
bleeding  vessels,  to  resect  the  corresponding  segment  of  the  gut,  as 
such  injuries  are  very  apt  to  be  followed  by  gangrene  of  that  part  of 
the  intestine  which  is  dependent  for  its  supply  upon  the  injured 
vessels.  The  incision  for  injuries  of  this  character  is  usually  made  in 
the  middle  line  four  or  five  inches  long,  reaching  from  the  umbilicus 
downward  toward  the  symphysis.  The  incision  may  be  prolonged 
upward  toward  the  ensiform  cartilage,  passing  to  the  left  of  the 
umbilicus.  The  operator  should  avoid  laying  the  abdomen  open  from 
the  ensiform  cartilage  down  to  the  symphysis  pubis  in  the  eagerness 
of  his  search  for  wounds  in  the  gut. 

After  the  abdomen  has  been  opened,  a  careful  and  systematic 
examination  is  made  of  the  intestine  from  one  end  to  the  other,  com- 
mencing at  the  lowest  part  of  the  ileum,  where  it  enters  the  caecum. 
This  part  of  the  gut  should  be  sought  and  drawn  out  upon  the 
abdomen  and  from  this  point  onward  the  small  intestine  and  mesentery 
are  carefully  inspected,  coil  after  coil  being  drawn  out  and  examined 
and  then  replaced,  continuing  thus  until  the  upper  end  of  the  gut  has 
been  reached. 

As  a  rule,  penetrating  gunshot  and  stab  wounds  of  the  abdomen 
are  accompanied  by  multiple  perforations  of  the  gut  and  mesentery — 
may  be  as  many  as  fifteen  or  twenty, — and,  when  one  perforation  in 
the  gut  is  located,  usually  a  second  is  found  in  the  same  segment  at  a 
corresponding  point  opposite.  Each  time  a  projectile  passes  through 
the  gut  it  makes  two  wounds — one  of  entrance  and  one  of  exit. 

Where, a  perforation  of  the  gut  is  located  the  mucous  membrane 
is  usually  found  protruding  and  tending  to  plug  up  the  opening, 
nature's  effort.  Here  we  pause,  replace  the  mucous  membrane,  wipe 
off  the  margins  of  the  opening  with  a  gauze  pad  moistened  with  alcohol 
followed  by  one  wet  with  saline  solution,  and  then  close  it  with  two 
or  three  interrupted  Lembert  sutures  of  fine  silk;  these  sutures  are 
placed  about  one-eighth  inch  apart  and  care  should  be  taken  to  invert 
the  edges  of  the  wound  and  to  bring  the  serous  surfaces  into  close 
apposition.  The  wounds  may  also  be  closed  with  a  purse-string  suture 
applied  in  a  circle  around  the  margin  of  the  opening.  In  suturing 
these  wounds  care  should  be  taken  not  to  reduce  the  calibre  of  the 
intestine  more  than  one-third. 

27 


418  ABDOMEN  AND  BACK. 

We  then  continue  in  the  search  for  further  wounds.  Those 
involving  the  mesenteric  border  of  the  gnt,  especially  if  the  adjoining 
mesentery  is  torn,  are  unfavorable  for  suture;  in  the  first  place,  the 
serous  coat  on  this  part  of  the  gut  is  imperfect,  has  a  "dead  space"; 
and,  in  the  second  place,  if  any  of  the  mesenteric  vessels  are  divided 
close  to  the  gut,  the  corresponding  segment  of  the  gut  on  account  of 
interference  with  the  blood-supply  is  apt  to  become  gangrenous;  there- 
fore it  is  wise,  in  many  of  these  cases,  to  resect  such  a  segment  of  gut 
at  once. 

Bleeding  vessels  in  the  mesentery  are  clamped  and  tied  with  plain 
catgut. 

After  the  whole  length  of  the  small  intestine  has  been  explored 
the  surgeon  should  examine  the  entire  length  of  the  large  intestine,  the 
stomach,  and  the  bladder  for  perforations,  and  look  further  for 
hemorrhage,  which  might  indicate  wounds  of  the  liver,  spleen,  kidneys, 
etc. 

Hemorrhagic  oozing  from  the  solid  viscera  is  usually  readily  con- 
trolled with  the  Paquelin  cautery  or  by  packing,  or  the  edges  of  a 
gaping  wound  may  be  brought  together  with  several  deep  catgut 
sutures,  although  these  tend  to  tear  through  if  much  tension  is  made. 
Any  spurting  vessels  in  the  solid  viscera  should  be  clamped  and  tied 
with  catgut. 

Having  thus  completed  the  examination  of  the  entire  length  of 
the  alimentary  canal,  etc.,  closed  all  wounds,  and  controlled  the 
hemorrhage,  the  whole  abdominal  cavity  may  be  flushed  out  with  hot 
saline  solution,  using  a  considerable  quantity — ^best  poured  from  a 
pitcher  in  order  to  wash  out  material  that  may  have  escaped  from  the 
stomach  and  intestine. 

During  the  search  for  wounds,  etc.,  the  gut  should  be. replaced, 
coil  after  coil,  as  fast  as  it  is  examined.  While  the  intestine  is  out- 
side the  abdomen  it  should  be  carefully  protected  with  hot  sterile 
towels,  which  may  be  wet  in  hot  saline  solution.  After  a  time  the  wet 
cloths,  if  not  repeatedly  wet  with  hot  water,  become  cooled ;  therefore 
some  surgeons  prefer  dry  sterile  compresses  for  this  purpose. 

If  necessary  to  have  a  considerable  portion  of  the  length  of  the 
gut  outside  upon  the  abdomen,  it  should  be  supported  so  that  it  does 
not  drag  upon  the  mesentery,  and  care  should  be  exercised  that  the 
gut  does  not  become  twisted  upon  its  mesentery  to  such  an  extent  as 
to  interfere  with  the  venous  return.  The  withdrawal  of  a  consider- 
able portion  of  the  length  of  the  gut  out  of  the  abdomen  should  be 
avoided  however,  as  much  as  possible,  as  the  shock  is  greatly  aug- 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  419 

mented  and  there  may  be  some  difficulty  experienced  in  returning  the 
distended  coils  of  gut  back  into  the  abdomen  again. 

If,  owing  to  the  distention  of  the  guts  with  gas,  it  becomes  difficult 
to  replace  them  within  the  abdomen,  it  may  be  necessary  to  puncture 
them  in  order  to  allow  the  gas  to  escape.  For  this  purpose  it  is 
better  to  make  a  rather  larger  opening  with  the  knife  and  introduce 
a  glass  tube  into  the  gut  in  either  direction  to  facilitate  the  escape 
of  gas,  etc.  The  incision  in  the  gut  is  aftenvard  closed  with  a  Lem- 
bert  suture. 

The  abdominal  incision  is  carefully  closed  layer  by  layer,  the  peri- 
toneum and  fascia  transversalis  with  plain  catgut,  the  edges  of  the 
muscle  with  several  stitches  of  plain  catgut  and  the  aponeurosis  with  a 
continuous  suture  of  chromic  catgut  and  finally  the  skin. 

For  Typhoid  Perforation. — Perforation  of  the  bowel  at  the 
site  of  an  ulcer  may  occur  any  time  during  the  course  of  typhoid  fever 
from  the  first  week  up  to  the  termination  of  the  disease.  Perforation 
occurs  most  commonly  during  the  third  week.  It  is  more  frequently 
seen  in  adult  males  than  females  and  is  rather  rarely  seen  in  children. 
Operation  saves  about  25  per  cent,  of  the  cases. 

The  perforation  is  found  in  the  ileum,  usually  the  last  two  feet,  in 
about  80  per  cent,  of  the  cases;  in  about  13  per  cent,  the  perforation 
is  located  in  the  large  intestine;  and  in  about  5  per  cent,  in  the 
appendix.  The  perforation  is  usually  single,  but  they  may  be  multiple. 
The  perforation  is  accompanied  by  peritonitis,  either  local  or  general. 
Perforation  of  ulcer  in  ''walking  cases"  of  typhoid  may  be  mis- 
taken for  cases  of  acute  gangrenous  appendicitis. 

Operation  should  be  undertaken  as  soon  as  the  diagnosis  is  made 
and  in  case  of  doubt  an  exploratory  incision  may  be  resorted  to.  This 
can  be  done  under  cocain  if  desirable. 

Incision  is  made  through  the  right  rectus  as  for  appendicitis  and 
should  be  sufficiently  liberal  so  as  to  permit  of  proper  work — may  be 
five  to  six  inches  long.  The  median  incision  from  the  umbilicus 
downward  is  sometimes  employed,  but  that  through  the  outer  part  of 
the  rectus  gives  much  better  access  to  the  portion  of  the  bowel  which 
is  usually  the  site  of  the  perforation.  When  the  abdomen  is  opened 
there  is,  as  a  rule,  an  escape  of  sero-purulent  fluid.  There  may  or  may 
not  be  some  inflammatory  adhesions  present  which  serve  the  purpose 
of  walling  off  the  damaged  portion  of  the  bowel  from  the  general 
peritoneal  cavity. 

The  caecum  is  sought  and  drawn  into  the  incision  and  used  as 
a  guide  to  the  appendix  and  commencement  of  the  small  intestine. 


420  ABDOMEN  AND  BACK.  • 

The  appendix,  if  perforated  or  seriously  affected,  is  removed.  Com- 
mencing at  tlie  csecum,  the  small  intestine  is  drawn  out,  coil  after  coil, 
and  carefully  inspected  and  wiped  clean  with  gauze  pads  or  it  may  be 
washed  with  salt  solution.  If  desired  this  investigation  may  be  con- 
tinued until  the  entire  small  intestine  has  been  examined.  If  the  coils 
of  gut  are  not  immediately  returned  to  the  abdominal  cavity  but  are 
retained  outside  the  abdomen,  they  must  be  supported  and  protected 
with  hot,  sterile  towels. 

The  perforations  vary  in  size  from  a  pinhead  to  a  fairly  large, 
ragged  opening.  Usually  there  is  only  one  perforation,  but  there  may 
be  several.  The  hole  in  the  gut  is  closed,  without  paring  its  edges, 
with  non-penetrating  sutures  of  silk.  A  purse-string  suture  may  be 
applied  around  the  margin  and  the  opening  thus  closed  or  one  or  two 
rows  of  interrupted  Lembert  sutures  can  be  used.  These  may  be 
applied  in  mattress  fashion.  It  is  immaterial  whether  the  opening  is 
closed  in  a  direction  longitudinal  or  transverse  to  the  long  axis  of  the 
gut,  but  care  must  be  taken  not  to  reduce  the  calibre  of  the  gut  too 
much — surely  not  more  than  one-third.  If  any  very  thin  areas  are 
encountered  during  the  examination  of  the  intestine  it  might  be 
advisable  to  take  a  stitch  or  two  in  such  portions  of  the  gut  in 
order  to  fortify  them  against  the  danger  of  perforation  later. 

If  the  opening  in  the  gut  can  be  closed  and  the  peritoneal  cavity 
thoroughly  cleansed  either  by  wiping  with  dry  gauze  pads  or  by 
irrigation  with  salt  solution,  it  may  be  permissible  to  close  the 
abdominal  incision  without  drainage.  In  doubtful  cases  it  is  well  to 
provide  for  drainage.  If  it  is  decided  to  use  drainage  a  plug  of  strip 
gauze  is  introduced  into  the  abdomen,  reaching  well  down  into  the 
pelvic  cavity.  The  abdominal  incision  is  closed  except  where  the 
drainage  strip  emerges.  Drainage  may  be  facilitated  by  keeping  the 
patient  in  a  partly  sitting  posture  after  the  operation. 

If  the  gut  is  badly  damaged  or  very  much  thickened  about  the 
perforation  or  presents  several  openings  close  together  it  may  be  wise 
to  resect  the  affected  portion  and  restore  the  continuity  of  the  gut 
by  an  end-to-end  anastomosis;  a  better  plan  under  these  conditions 
would  probably  be  to  draw  the  damaged  coil  of  gut  out  of  the  abdomen 
and  fix  -it  to  the  edges  of  the  incision  with  several  non-penetrating 
sutures  of  chromic  catgut  and  thus  establish  an  intestinal  fistula  (see 
"Enterostomy" ) . 

If  it  is  found  at  the  time  of  operation  that  the  soiling  of  the 
peritoneum  has  been  general  it  may  be  advisable  to  turn  the  entire 
small  intestine  out  of  the  abdomen  in  order  to  cleanse  the  peritoneal 


OPEEATIONS  UPON  THE  SMALL  INTESTINE. 


421 


cavity  either  by  wiping  with  dry,  sterile  gauze  pads  or  else  by  irrigating 
with  saline  solution ;  after  the  intestines  have  been  treated  in  a  similar 
manner  they  are  returned  to  the  abdomen.  Drainage  is  arranged  in 
these  cases  as  already  indicated  above. 


Fig.  192.— Enterectomy.  A  loop  of  intestine  has  been  drawn  out  ttirough 
the  abdominal  incision  and  tied  off  with  tapes.  The  mesentery  corresponding 
to  the  portion  of  gut  that  is  to  be  excised  has  been  tied  off  in  sections.  The 
dotted  lines  indicate  the  lines  of  section  through  the  mesentery  and  gut. 

Enterectomy. — Eesection  of  a  portion  of  the  gut  (small  intes- 
tine) ;  the  length  of  gut  resected  may  vary  from  several  inches  to 
several  feet.  The  operation  is  performed  for  wounds  which  may  not 
be  safely  closed  by  suture;  for  those  associated  with  division  of  the 


422  ABDOMEN  AND  BACK. 

mesenteric  vessels,  especially  if  they  are  divided  close  to  the  intestine; 
for  malignant  growths;  for  gangrene,  strangulation;  for  fistula,  etc. 

The  incision  is  usually  made  in  the  middle  line,  four  or  five  inches 
long,  reaching  from  the  umbilicus  downward  toward  the  symphysis  or 
corresponding  to  the  location  of  the  fistulous  opening  if  one  is  present. 
The  portion  of  intestine  to  be  resected  should  be  gently  freed  from 
adhesions,  if  there  are  any,  and  brought  out  upon  the  abdomen, 
together  with  an  adjoining  portion  of  healthy  gut,  four  to  six  inches 
to  either  side  of  the  part  which  is  to  be  resected;  the  gut  should  be 
supported  u]oon  dry,  sterile  gauze  compresses,  some  of  which  are  also 
tucked  into  the  abdominal  incision  to  protect  the  peritoneal  cavity. 

In  order  to  prevent  the  escape  of  intestinal  contents  during  the 
operation,  two  pieces  of  narrow  tape  are  tied  around  the  gut,  one 
beyond  each  extremity  of  the  segment  which  is  to  be  excised.  In 
■order  to  carry  the  tapes  around  the  gut,  a  thin-nosed  artery  forceps 
is  thrust  through  the  mesentery  close  to  the  gut  and  with  this  the 
end  of  the  tape  is  seized  and  pulled  through.  One  tape  is  tied  and 
the  contents  of  the  gut  gently  stroked  along  with  the  fingers  beyond 
the  second  tape  and  then  this  is  tied  also.  We  have  thus  a  fairly 
empty  coil  to  operate  upon,  the  tapes  being  tied  just  tight  enough 
to  prevent  the  re-entrance  of  contents.  The  tapes  should  be  applied 
to  the  gut  at  a  sufficient  distance  beyond  the  portion  which  is  to  be 
excised  to  allow  convenient  working  space. 

We  then  proceed  to  separate  the  portion  of  gut  that  is  to  be  excised 
from  its  mesenteric  attachment.  This  is  done  by  tying  the  mesentery 
off  in  segments,  each  ligature  including  about  one  inch  of  the  length  of 
the  mesentery;  the  ligatures  should  be  of  thin  catgut  (No.  1  or  2),  and 
■each  tied  single  about  one  inch  away  from  the  mesenteric  edge  of  the 
gut  in  order  to  leave  room  to  divide  the  mesentery  between  the 
ligatures  and  the  gut.  These  ligatures  may  be  passed  either  with  a 
narrow-bladed  artery  forceps  or  a  blunt  ligature  carrier.  One  must  be 
■careful  not  to  tie  off  a  greater  length  of  mesenter}'-  than  that  which 
•actually  corresponds  to  the  segment  of  gut  which  is  to  be  excised, 
because  gut  which  has  been  deprived  of  its  mesentery  is  deprived  of  its 
blood-supply  and  is  bound  to  slough.  The  surgeon  should  rather  err 
in  the  other  direction,  tying  off  a  little  less  mesentery  than  that  which 
corresponds  to  the  length  of  the  segment  of  the  gut  that  is  to  be 
excised.  After  the  mesentery  has  been  thus  tied  off,  the  segment  of 
gut  that  is  to  be  excised  is  cut  away  from  its  mesenteric  attachment, 
using  the  straight  scissors  and  cutting  between  the  ligatures  and  the 
gut;  the  point  of  the  scissors  should  be  introduced  into  the  openings 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  423 

made  by  the  ligatures  and  the  mesentery  cut  from  hole  to  hole  and 
thus  finally  through  into  the  last  ligature  opening.  We  are  then  ready 
to  sever  the  gut  and  this  is  done  with  long,  straight  scissors  that  will 
divide  the  gut  in  one  clean  sweep.  The  gut  is  divided  straight  across 
at  right  angles  to  its  long  axis,  or,  still  better,  somewhat  obliquely,  so 
that  the  segment  of  gut  excised  measures  rather  more  upon  its  distal 
border  than  upon  its  mesenteric  border.  Bleeding  points  on  the  cut 
edges  of  the  intestine  are  clamped,  but,  as  a  rule,  these  do  not  require 
ligation,  since  after  a  few  moments'  pressure  or  after  the  ends  of  the 
gut  have  been  sutured,  the  hemorrhage  usually  stops.  Spurting 
arterial  points,  however,  should  be  clamped  and  tied  with  fine  catgut. 
Contents  that  escape  from  the  ends  of  the  bowel  are  sponged  away  and 
care  should  be  taken  that  the  pads  of  gauze  are  so  arranged  as  to  pre- 
vent the  entrance  of  any  of  this  material  into  the  abdominal  cavity. 

We  are  now  ready  to  restore  the  continuity  of  the  intestinal  canal. 
This  step  may  be  accomplished  by  any  one  of  the  several  procedures 
that  are  described  below. 

1.  End-to-end  anastomosis,  the  most  desirable. 

(a)    Suture. 

(&)  Invagination  and  suture  (Mounsell). 

(c)  Suture  by  Connell  method. 

(d)  Murphy  button. 

2.  Side-to-side,  or  lateral,  anastomosis;  applicable  to  both  small 
and  large  intestine. 

(a)   Suture. 

(&)   Murphy  button. 

(c)   McGraw's  rubber  ligature. 

3.  End  to  side;  this  method  is  used  to  join  the  ileum  to  the 
large  intestine  (see  "Eesection  of  Cgecum")  and  to  join  the  end  of 
the  duodenum  to  the  stomach  after  pylorectomy  (see  "Pylorectomy, 
Kocher"),  etc. 

End-to-End  Anastomosis.  Suture  (McGrath). — The  ends  of  the 
intestine,  after  they  have  been  cleansed  and  wiped  with  a  gauze  pad 
moistened  with  saline,  are  sewed  together  all  around  with  a  through- 
and-through  suture  of  chromic  catgut. 

Two  straight  cambric  needles  are  threaded  on  a  piece  of  chromic 
catgut.  No,  1,  about  twenty-four  inches  long  and,  with  this  the  two 
ends  of  the  bowel  are  joined  together  at  their  mesenteric  border  in 
such  a  manner  that  the  "dead  spaces"  are  obliterated  and  the  serous 
surfaces  are  secured  and  brought  into  accurate  and  close  apposi- 
tion.    The  proper  application  of  this  mesenteric  suture  is  essential 


434 


ABDOMEN  AND  BACK. 


to  the  success  of  the  operation.  The  mesenteric  border,  "dead 
space/^  is  likely  to  be  the  weak  point  in  end-to-end  anastomosis, 
and  this  suture  secures  it  absolutely.  The  stitch  passes  through  the 
edge  of  the  gut  at  the  mesenteric  border,  piercing  the  gut  from  its 
mucous  aspect  about  one-quarter  inch  away  from  its  edge;  it  trav- 
erses the  "dead  space"  and  pierces  the  mesenteric  serous  layer;  it 
then  pierces  the  mesenteric  serous  layer  of  the  other  end  of  bowel, 
passes  through  the  "dead  space"  and  the  edge  of  the  gut,  emerging 
upon  the  mucous  surface  of  the  second  piece  of  the  bowel.     Here 


Fig.  193.— End-to-End   Anastomosis.      The   mesenteric   suture   lias  been   intro- 
duced.    Note  how  it  traverses  the  "dead  space." 

it  turns  back,  forming  a  loop  upon  the  mucous  surface  of  the  second 
end  of  bowel  and,  traveling  in  the  reverse  direction  to  that  already 
described,  it  passes  again  through  the  two  ends  of  the  bowel  and 
finally  emerges  upon  the  mucous  surface  of  the  first  end  of  bowel 
alongside  of  the  point  where  it  originally  started.  It  will  be 
observed  that  when  this  suture  is  drawn  tight  and  tied  it  brings 
the  two  ends  of  the  gut,  corresponding  to  their  mesenteric  borders, 
together  very  accurately  and  obliterates  the  "dead  spaces"  and 
necessarily  brings  the  mesenteric  serous  surfaces  into  close  apposi- 
tion with  each  other.     The  two  threads  corresponding  to  the  tails 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


425 


of  the  suture,  and  each  provided  with  a  needle,  are  used  to  unite 
the  corresponding  edges  of  the  two  ends  of  the  gut,  sewing  around 


Fig.  194. — End-to-End  Anastomosis.  Mesenteric  suture,  A,  drawn  tight  and 
tied.  Shows  accurate  apposition  of  the  mesenteric  borders  of  the  gut  and  com- 
plete obliteration  of  the  "dead  space." 


Fig.  195. — End-to-End  Anastomosis.  Edges  of  gut  seized  with  self-holding 
forceps  at  A.  Edges  of  gut  sutured  from  A  as  far  as  B  with  one  of  the  tails  of 
the  mesenteric  suture. 

one  side  with  one  needle  and  around  the  other  side  with  the  other 
needle,  and  commencing  with  each  at  the  fixed  point,  the  mesen- 
teric border,  which  is  identified  in  the  illustration  as  point  A.     To 


426  ABDOMEN  AKD  BACK. 

facilitate  the  introduction  of  the  suture  the  edges  of  the  gut  corre- 
sponding to  the  mesenteric  stitch  A  are  secured  in  the  grasp  of  a 
toothed  holding-forceps.  With  one  needle  we  sew  from  the  mesen- 
teric stitch  A  around  one  side,  uniting  the  edges  of  the  gut  toward 
B  nearly  half-way  around,  and  with  the  other  needle  from  point  A 
around  the  other  side,  uniting  the  edges  of  the  gut  toward  the 
point  C.  The  line  of  suture  should  be  inserted  a  quarter  of  an  inch 
below  the  edges  of  the  gut  so  as  to  insure  catching  both  edges  with 


Fig.  196. — End-to-End  Anastomosis.    The  edges  of  the  gut  sutured  together  from. 
A  as  far  as  C  with  the  other  tail  of  the  mesenteric  suture. 

each  stitch.  The  individual  stitches  should  be  not  more  than  one- 
eighth  inch  apart,  and  each  drawn  fairly  tight.  The  ends  of  the 
bowel  have  thus  been  sewed  together  for  considerably  more  than 
two-thirds  of  their  circumference.  When  the  gut  is  pulled  out  in 
a  straight  line  there  is  seen  to  remain  an  opening  corresponding 
to  less  than  one-third  of  the  circumference  still  to  be  closed.  The 
needles  are  thrust  through  the  edge  of  the  bowel  so  that  they  pre- 
sent upon  the  outer  surface,  and  partly  with  one  needle  and  partly 
with  the  other  the  opening  that  still  remains  is  closed.  A  Lembert 
stitch  is  used  for  this  purpose.  Each  stitch  takes  a  good  deep 
bite  even  at  the  risk  of  penetrating  into  the  mucous  layer.  Finally 
the  anastomosis  is   completed  by   tying  the   two   threads   together. 


OPERATIONS  UrON  THE  SMALL  INTESTINE.  427 

The  lines  of  union  of  the  two  ends  of  gut  may  be  reinforced  by 
applying  a  silk  Lembert  suture  all  around.  This  is,  however,  as  a 
rule  unnecessary,  yet  it  is  easily  and  quickly  applied  after  the  ends 
of  the  gut  have  been  joined  together  as  described  above. 

The  hole  that  is  left  in  the  mesentei-y  after  the  segment  of 
gut  has  been  resected  and  the  ends  sutured,  is  closed  with  several 
sutures  of  catgut.  These  sutures  should  not  be  tied  so  tightly  as 
to  obliterate  the  vessels  that  may  be  included  in  their  grasp  and 
which  are  necessary  for  the  supply  of  the  gut  at  the  line  of  junction. 

The  constricting  strips  which  were  placed  around  the  gut  are 
removed  and  the  sutured  bowel  returned  into  the  abdomen. 

Mounsell's  Method. — After  the  segment  of  gut  has  been 
excised  as  above  described,  the  cut  ends  are  placed  close  together 


Fig.  197.— End-to-End  Anastomosis.  The  axis  of  the  gut  restored.  The 
opening  that  still  remains,  less  than  one-third  of  the  circumference,  is  closed 
with  a  Lembert  suture,  using  both  tails  of  mesenteric  suture  in  part  to  accom- 
plish this.  A  shows  location  of  the  mesenteric  suture.  B  and  C  where  the 
needles  are  thrust  through  the  edges  of  the  gut  preparatory  to  Introducing  the 
final  Lembert  suture  that  closes  the  opening  that  remains. 

edge  to  edge  and  supported  outside  the  abdomen  upon  gauze  pads. 
With  a  moderately  large,  straight  needle  and  fairly  thick  silk  the 
edges  of  the  cut  ends  of  the  gut  are  fixed  to  each  other  at  four 
different  points  of  their  circumference  equidistant  from  one  another. 
These  sutures  are  to  serve  simply  as  tractors.  The  first  is  applied 
at  a  point  corresponding  to  the  mesenteric  attachment,  the  second 
at  a  point  directly  opposite  this,  and  the  other  two  at  points  mid- 
way between  these.  Each  of  these  sutures  should  include  all  the 
coats  of  the  gut,  special  care  being  taken  to  catch  the  mucous  mem- 
brane and  the  serous  coats.  Each  suture  is  applied  from  within  the 
gut,  so  that,  when  tied,  the  knot  will  be  upon  the  inner,  mucous 
membrane  aspect  of  the  gut.  As  each  of  these  four  tractor  sutures 
is  passed,  it  is  immediately  tied  and  one  end  cut  short,  leaving  the 


428 


ABDOMEN  AND  BACK. 


other  end  long.     In  tying,  the  sutures  should  be  tied  rather  loosely 
so  that  after^vard  they  may  be  readily  removed. 

In  one  or  the  other  segment  of  the  gut,  a  longitudinal  incision 
is  then  made.  This  incision  is  placed  opposite  the  mesenteric  bor- 
der, should  be  about  one  inch  long,  and  commences  about  one  and 
one-half  inches  distant  from  the  cut  edge  of  the  gut.  Through 
this  incision  a  narrow  artery  forceps  is  passed  into  the  gut  and  the 
tails  of  the  four  tractor  sutures  seized  and  pulled  through,  thus 
drawing  the  ends  of  the  gut  after  them,  with  the  result  that  the 
one  segment  of  gut  is  invaginated  into  the  other,  their  serous  sur- 
faces lying  in  contact  with  each  other  and  their  corresponding  edges 


Fig.  198. — End-to-End  Anastomosis  (Mounsell).  The  four  tractor  sutures 
have  been  introduced,  the  ends  seized  with  a  forceps  passed  through  an  incision 
in  one  segment  of  the  gut. 

in  apposition  all  around.  The  four  tractor  sutures  are  held  by 
assistants  and  put  somewhat  upon  the  stretch  and  then  the  corre- 
sponding edges  of  both  segments  of  the  gut  are  ready  to  be  joined 
by  suture.  The  edges  are  sewed  together  with  a  through-and-through 
stitch,  using  a  straight  needle  and  chromic  catgut.  This  suture 
should  be  applied  about  one-quarter  inch  below  the  edges  of  the 
gut  so  as  to  leave  a  margin  that  wide  between  the  suture  line  and 
the  edges  of  the  gut.  The  stitches  should  be  placed  quite  close 
together  (intervals  of  one-eighth  inch  between  the  needle  punctures) 
and  each  stitch  should  be  drawn  fairly  tight.  In  order  to  avoid  a 
"puckering  or  purse-string^'  effect  in  the  suture  a  '^Dack-stitch"  should 
be  taken  every  fourth  or  fifth  puncture. 

After  the  edges  of  the  segments  of  the  gut  have  been  united 
as  above  described,  the  temporary  tractor  sutures  are  removed  and 


OPERATIONS  UPON  THE  SjMALL  INTESTINE.  429 

the  gut  restored  to  its  natural  position  by  reducing  the  invagina- 
tion. The  incision  in  the  gut  is  closed  with  a  continuous  Lembert 
stitch. 

All  around  the  circular  junction  of  the  segments,  after  swab- 
bing with  a  pad  moistened  with  alcohol,  followed  by  one  wet  with 


Fig.  199. — End-to-End    Anastomosis     (Mounsell).      Shows    how    the    ends    of 
the  gut  are  invaginated  by  pulling  upon  the  tractors. 

saline  solution,  a  continuous  Lembert  stitch  of  fine  silk  may  be 
applied;  this  suture  still  further  inverts  the  edges  of  the  gut  and 
buries  completely  the  penetrating,  through-and-through  suture. 
This  additional  outside  line  of  suture  is  considered  unnecessary  by 
most  surgeons,  especially  if  the  through-and-through  suture  has  been 
accurately  applied. 


Fig.  200. — End-to-End  Anastomosis  (Mounsell).  The  two  ends  of  the  gut 
have  been  drawn  through  the  incision  in  the  gut.  The  tractors  are  held  taut 
and  the  edges  of  the  two  ends  of  gut  united  aU  around  with  a  through-and- 
through  suture. 

CoNNELL  Method. — According  to  this  plan  a  through-and- 
through,  right-angled  suture  is  employed.  The  edges  of  the  two 
ends  of  the  gut  that  are  to  be  united  are  held  in  apposition  during 
the  application  of  the  suture  with  four  tractor  sutures.  The  first 
tractor  secures  the  edge  of  either  end  of  the  gut  at  its  mesenteric 


430  ABDOMEN  AND  BACK. 

border.  A  second  tractor  pierces  tlie  edge  of  each  segment  of  the 
bowel  at  a  point  a  little  more  than  half-way  between  the  mesenteric 
border,  where  suture  No.  1  has  been  introduced,  and  the  distal 
border.  Tractors  Nos.  3  and  4  each  catch  the  edge  of  the  corre- 
sponding segment  of  the  bowel  at  a  point  the  same  distance  from 
its  mesenteric  border  as  suture  No.  2,  but  upon  its  opposite,  the 
outer,  border.  These  four  tractors  are  introduced  simply  for  the 
purpose  of  facilitating  the  application  of  the  suture  that  is  to  unite 
the  two  ends  of  the  bowel.  They  are  of  silk  and  as  they  are 
drawn  taut  they  convert  the  end  of  each  segment  of  the  gut  into 
a  triangular-shaped  opening. 

The  second  step  of  the  operation  consists  in  suturing  the  ends 
of  the  two  segments  of  the  bowel  to  each  other  all  around.  This 
is  accomplished  with  a  through-and-through,  right-angled  suture. 
While  the  gut  is  steadied  by  tractors  Nos.  1  and  2,  held  by  the 
assistant,  the  apposed  edges  of  the  gut  are  sutured  together,  com- 
mencing near  tractor  No.  2  and  working  toward  and  a  little  beyond 
tractor  No.  1,  which  marks  the  mesenteric  border  of  the  gut.  In 
this  way  the  union  between  the  two  ends  of  gut  is  accomplished 
for  the  first  third  of  their  circumference.  After  the  first  stitch 
has  been  introduced  the  thread  is  tied,  the  tail  of  the  suture  being 
left  long. 

Tractor  No.  2  is  then  cut  away  and  traction  made  with  tractor 
No.  .1.  At  the  same  time  tractors  Nos.  3  and  4  are  drawn  around 
so  as  to  approximate  the  corresponding  edges  of  the  two  ends  of 
the  gut  for  that  portion  of  their  circumference  which  is  included 
between  tractor  No.  1  and  tractors  Nos.  3  and  4.  With  the  same 
needle  and  thread  these  portions  of  the  edges  of  the  gut  are  then 
united,  working  from  tractor  No.  1  toward  and  a  little  beyo^id  trac- 
tors Nos.  3  and  4,  and  thus  the  edges  of  the  gut  are  united  for  the 
second  third  of  their  circumference.  The  line  of  suture  should  be 
placed  one-quarter  inch  away  from  the  edges  of  the  bowel  so  as 
to  leave  a  margin  that  wide.  The  stitches  should  be  placed  close 
together- — the  needle  punctures  one-eighth  inch  apart — and  a  ^^Dack- 
stitch"  should  be  made  at  every  fourth  or  fifth  puncture  in  order 
to  fix  the  suture  and  avoid  the  "purse-string,"  or  puckering,  effect. 

The  remaining  tractors,  Nos.  1,  3,  and  4,  are  removed  and  we 
then  proceed  to  suture  the  edges  of  the  bowel  for  the  last  third  of 
their  circumference.  As  this  must  be  done  without  the  assistance 
of  the  tractors,  attention  must  be  given  to  the  detail  of  the  stitch. 
The  needle  is  thrust  through  the  edge  of  the  one  segment  of  the 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  43I 

gut,  entering  upon  its  mucous-membrane  aspect  immediately  adja- 
cent to  the  point  where  it  last  emerged,  and  then  the  needle  is 
carried  across  to  the  other  segment  of  the  bowel,  and  this  is  pierced 
near  its  edge,  penetrating  from  the  serous  surface  and  emergnig 
upon  its  mucous  aspect.  To  make  each  successive  stitch  the  needle 
is  thrust  through  the  edge  of  the  same  segment  of  the  bowel  and 
just  alongside  of  where  it  last  emerged,  penetrating  from  the  mucous 
to  the  serous  surface,  then  across  to  the  other  segment  of  the  bowel, 
which  it  pierces  from  the  serous  to  the  mucous  surface.  As  each 
stitch  is  introduced  the  thread  is  drawn  tight.  Toward  the  end, 
the  last  few  stitches  are  left  a  little  slack  so  as  to  allow  sufficient 
room  for  the  manipulation  that  is  necessary  in  introducing  the 
terminal  stitches.  The  last  puncture  of  the  needle  as  it  completes 
the  suture  should  show  the  thread  emerging  upon  the  mucous-mem- 
brane aspect  of  the  gut  immediately  adjacent  to  the  tail  that  has 
been  tied,  and  which  marks  the  commencement  of  the  suture.  The 
tail  of  thread  that  corresponds  to  the  termination  of  the  suture 
should  be  left  longer  than  the  tail  that  is  tied  and  which  marks 
the  commencement  of  the  suture  in  order  that  it  may  be  thus 
identified. 

The  last  step  of  the  operation  consists  in  tying  the  ends  of  the 
thread  so  that  the  knot  will  be  within  the  lumen  of  the  gut.  The 
end  of  a  narrow,  straight,  ligature  carrier  is  introduced  into  the 
bowel  between  the  stitches  at  a  distance  of  about  three-fourths  of 
an  inch  away  from  the  space  through  which  the  two  ends  of  the 
suture  emerge.  The  point  of  the  carrier  is  pushed  out  through  this 
space  (through  which  the  suture  ends  emerge)  and  the  ends  of  the 
suture  are  threaded  into  its  eye.  The  instrument  is  then  with- 
drawn, pulling  the  tails  of  the  suture  after  it.  A  little  traction  is 
made  upon  the  longer  of  the  two  suture  ends  in  order  to  tighten 
up  the  slack  of  the  last  few  stitches.  The  ends  are  then  tied  and 
cut  short.  By  rolling  the  bowel  between  the  fingers  the  knot  will 
be  made  to  slip  into  the  lumen  of  the  gut. 

With  Murphy  Button. — Having  resected  the  gut  as  above 
described,  a  running  string  is  placed  in  the  edge  of  each  segment 
of  the  gut  which,  when  drawn  tight  and  tied,  puckers  the  end  of 
the  gut  and  grasps  the  button  about  its  shank,  leaving  the  flange 
or  cup  of  the  button  within  the  gut.  This  running  stitch,  or  purse- 
string,  is  applied  in  overhand  fashion,  is  of  chromic  catgut  and 
carried  upon  two  long,  straight  needles,  one  at  each  end.  This 
stitch  includes  all  the  layers  of  the  gut,  especially  the  serous  and 


433 


ABDOMEN  AND  BACK. 


the  mucous  membrane;  it  should  not  include  too  wide  a  margin  of 
the  gu.t,  since  the  amount  of  tissue  which  is  grasped  between  the 
flanges,  or  cups,  of  the  button  may  be  too  bulky  to  allow  exact 
coaptation;  a  margin  of  rather  less  than  one-fourth  inch  is  suffi- 
cient.    The  running  stitch  is  commenced  by  piercing  the  mesentery 


Fig.  201. — End-to-End  Anastomosis  (Murphy  Button).  With  the  purse-string 
suture  a  loop  is  taken  through  the  layers  of  the  mesentery,  close  to  the  wall  of 
the  gut,  in  order  to  obliterate  the  "dead  space." 

close  to  the  surface  of  the  gut,  and  then,  carrying  the  same  needle 
back  over  the  edge  of  the  mesentery,  it  is  again  thrust  through, 
so  that  we  thus  have  a  loop  around  the  cut  edge  of  the  mesentery 
close  to  the  surface  of  the  gut.  With  this  same  needle  the  running 
suture  is  applied  to  the  corresponding  half  of  the  circumference 
of  the  cut  edge  of  the  gut ;  each  puncture  of  the  needle  should  be 
made  from  within  the  lumen  "of  the  gut,  from  its  mucous-membrane 
aspect,    and   the   punctures   should   be   about   one-third   inch    apart. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  433 

When  a  point  is  reached  directly  opposite  the  mesenteric  border  of 
the  gut,  this  needle  is  discarded;  the  second  needle  is  then  taken 
in  hand  and  the  second  half  of  the  circumference  of  the  gut  treated 
in  exactly  the  same  manner.  In  this  way  the  whole  circumference 
of  the  gut  is  included,  leaving  the  two  free  tails  of  the  suture  which 
emerge  upon  the  serous  surface  of  the  gut  opposite  its  mesenteric 
attachment,  ready  for  tying. 

One-half  of  the  button,  grasped  with  a  thumb  forceps  by  the 
edge  of  its  tubal  part,  is  introduced  into  the  end  of  the  gut,  turning 
the  button  a  little  on  the  side  to  facilitate  its  introduction,  and 
while  it  is  thus  held  the  purse-string  is  tied  around  its  shank,  leav- 
ing the  flange  within  the  intestine.  The  ends  of  the  purse-string 
are  cut  short  so  that  they  will  not  protrude  between  the  flanges  of 
the  button  when  this  is  closed.  This  procedure  is  repeated  upon 
the  other  segment  of  gut.  The  two  halves  of  the  button  are  then 
deliberately  pressed  home,  and  in  doing  this  one  should  note  that 
the  corresponding  mesenteric  attachments  of  both  segments  of  the 
gut  are  opposite  each  other. 

When  the  two  halves  of  the  button  are  locked  there  should  be 
presented  between  them  a  clean,  smooth  line  with  no  raw  mucous- 
membrane  edge  protruding,  and  at  the  mesenteric  attaclmient  the 
apposition  of  serous  surfaces  should  also  be  assured. 

Although  it  is  probably  not  necessary  in  most  cases  to  use  a 
layer  of  Lembert  sutures  in  addition  to  the  Murphy  button  to  secure 
accurate  apposition,  nevertheless  it  is  wise  in  many  cases  to  place  a 
continuous  Lembert  stitch  outside  of  the  button  after  the  halves 
have  been  pressed  home,  especially  as  the  presence  of  the  button  makes 
the  application  of  this  stitch  rather  an  easy  matter. 

Side-to-Side,  or  Lateral,  Approximation  (Lateral  Intestinal  Anas- 
tomosis).— This  is  the  formation  of  a  fistulous  opening  between  two 
coils  of  intestine  joined  side  to  side. 

This  operation  is  indicated  when  the  ends  of  gut  that  are  to 
be  united  differ  much  in  calibre, — for  example,  to  unite  the  end  of 
the  ileum  to  the  csecum.  It  may  be  accomplished  by  suture,  clamps. 
Murphy  button,  or  McGraw  rubber  suture,  etc. 

Suture. — The  intestine  is  brought  well  up  into  the  wound  or.  if 
possible,  outside  upon  the  abdomen,  and  surrounded  with  gauze  pads 
to  protect  the  peritoneal  cavity.  Gauze  strips  or  tapes  are  tied 
around  the  intestine,  and  after  the  diseased  portion  has  been  excised 
the  cut  end  of  each  segment  of  the  gut  is  inverted  and  closed  with  a 

23 


434  ABDOMEN  AND  BACK. 

double  row  of  Lembert  sutures,  thus  converting  each  end  of  the  gut 
into  a  blind  pouch.  Care  should  be  taken  to  include  the  invaginated 
mesentery  in  the  suture.  The  invagination  of  the  end  of  the  gut 
is  commenced  at  its  mesenteric  border,  inverting  a  margin  about 
one  inch  in  width. 

The  next  step  is  the  imion  of  the  two  blind  ends  of  the  gut  to 
each  other,  side  to  side,  and  in  such  a  manner  that  the  intestinal 
canal,  through  the  new  opening  that  is  to  be  made,  will  be  con- 
tinued in  a  direct  line,  and  not  reversed  in  passing  from  one  seg- 
ment into  the  other.  The  ends  of  the  gut  should  be  so  placed  that 
they  overlap  each  other  for  a  distance  of  four  to  five  inches.  Their 
apposed  lateral  surfaces  are  then  united  to  each  other  for  a  distance 
of  from  three  to  four  inches  by  a  single  row  of  continuous  Lembert 
sutures  of  fine  silk.  After  this  row  of  Lembert  suture,  which  forms 
the  posterior  half  of  the  "outside  serous  ring,"  has  been  applied, 
the  needle,  still  carrying  the  silk  thread,  is  laid  aside  until  required 
later  to  complete  this  "outside  serous  ring."  This  line  of  Lembert 
sutures  should  be  one  inch  longer  than  the  proposed  openings  in 
the  gilt  and  each  stitch  should  be  rather  less  than  one-eighth  inch 
distant  from  its  neighbor  and  should  be  drawn  tight. 

Each  segment  of  the  bowel  is  now  opened  with  the  scissors,  the 
incisions  being  placed  about  one-fourth  inch  distant  from  the  line 
of  the  Lembert  suture;  the  openings  in  the  bowel  should  be  large 
so  as  to  allow  for  subsequent  contraction, — three  inches  long  and 
at  least  one  inch  shorter  than  the  line  of  the  Lembert  suture. 

Bleeding  from  the  edges  of  the  incisions  in  the  bowel  is  controlled 
with  artery  clamps  which  may  be  removed  after  a  few  minutes^  pres- 
sure, as  the  hemorrhage  usually  ceases.  The  edges  of  the  openings 
in  the  gut  are  wiped  with  alcohol  followed  by  saline  solution,  and  then, 
with  a  continuous  suture  of  chromic  catgut  which  at  the  same  time 
controls  the  hemorrhage,  the  edges  of  the  openings  in  the  bowel  are 
united  with  each  other  all  around.  Having  thus  united  the  edges  of 
the  openings  all  around,  we  again  take  up  the  needle  carrying  the 
original  silk  suture  and  complete  the  anastomosis  by  making  the 
anterior  half  of  the  Lembert  suture,  the  "outside  serous  ring." 

In  making  the  lateral  anastomosis  one  should  not  have  the  blind 
ends  of  the  overlapped  gut  too  long.  These  ends  are  anchored  to  the 
adjoining  wall  of  the  intestine  by  several  Lembert  stitches. 

It  may  be  necessary  to  tear  the  mesentery  somewhat  in  order  to 
allow  sufficient  overlapping  of  the  ends  of  the  bowel.  After  the 
anastomosis  has  been  made,  the  overlapping  layers  of  the  mesentery  are 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


435 


Fig.  202. — Lateral  Anastomosis.  The  end  of  each  coil  of  gut  has  heen  closed 
by  suture.  The  two  coils  have  been  placd  side  by  side  and  joined  by  a  continu- 
ous non-penetrating  suture.  An  opening  has  been  made  in  the  side  of  each 
coil  of  gut. 


Fig.  203. — Lateral   Anastomosis   with    Murphy   Button.     A   purse-string   has   been 
introduced  in   both  segments.     One  segment  has  been   incised. 


436  ABDOMEN  AND  BACK. 

united  with  a  continuous  catgut  suture  loosely  applied  in  order  to 
obliterate  any  spaces  or  holes  into  which  a  coil  of  gut  might  find  its 
way  and  become  strangulated.  When  the  anastomosis  is  complete  it 
will  be  seen  that  the  two  segments  of  gut  are  united  side  to  side. 

With  Clamps. — A  fold  of  the  wall  of  each  of  the  two  segments 
of  gut  that  are  to  be  joined  together  is  grasped  between  the  blades  of 
the  holding  forceps,  the  blades  sheathed  with  rubber  tubing.  The  fold 
secured  in  the  grasp  of  the  forceps  is  .about  four  inches  long.  The 
wall  of  each  segment  of  gut  is  grasped  in  such  a  manner  that  the  folds 
in  the  blades  of  the  forceps  will  correspond  to  the  lateral  wall  of  the 
gut  and  be  opposite  each  other.  The  forceps  are  placed  with  the 
blades  holding  the  folds  of  intestine  side  by  side  (see  Figs.  211,  213, 
214),  and  the  two  folds  of  gait  are  joined  together  with  a  continuous 
non-penetrating  suture  of  silk  for  a  distance  of  three  inches.  When 
this  line  of  suture  has  been  completed  the  needle  is  laid  aside  tempo- 
rarily until  needed  later  to  complete  this  outside  ring  of  suture.  An 
incision  two  and  one-half  inches  long  is  made  in  each  of  the  folds  of 
gut  which  are  grasped  with  the  forceps,  about  one-quarter  inch  distant 
from  and  parallel  with  the  suture  line  that  unites  the  two  folds.  This 
incision  penetrates  the  serous  and  muscular  coats,  the  edges  of  which 
retract,  exposing  an  elliptical  area  of  the  mucous  layer,  which  is  excised 
with  a  sharp-pointed  scissors.  Hemorrhage  from  the  edges  is  con- 
trolled by  tightening  the  clamps  and  ligating  spurting  points.  The 
corresponding  edges  of  the  incisions  in  the  bowel  are  sewed  to  each 
other,  all  around  with  a  continuous  suture  of  chromic  catgut.  The 
clamps  are  then  removed  and  the  needle  carrying  the  thread  with  which 
the  first  line  of  non-penetrating  Lembert  suture  was  introduced  is 
again  taken  up  and  used  to  apply  the  anterior  half  of  the  outside 
serous  ring  suture  and  thus  complete  the  operation. 

With  Mukphy  Butto>sT.' — ^  lateral  intestinal  anastomosis  may 
be  made  with  the  Murphy  button.  After  the  ends  of  the  gut  have 
been  inverted  and  closed  with  a  suture  as  described  in  the  preceding 
operations,  the  two  ends  are  placed  side  by  side  and  a  purse-string 
placed  in  the  lateral  wall  of  each  segment.  The  purse-string  consists 
of  two  parallel  rows  with  a  space  between  them  of  not  more  than  one- 
half  i]ich,  so  that  when  the  incision  is  made  there  will  be  a  margin  on 
each  side  of  about  one-fourth  inch.  Each  leg  of  the  suture  should  be 
made  with  three  punctures  of  the  needle,  penetrating  the  entire 
thickness  of  the  bowel  with  each  thrust.  Either  silk  or  chromic  cat- 
gut may  be  used  as  suture  material.  The  writer  prefers  catgut.  The 
first  double  loop  of  a  surgeon's  knot  is  taken  with  the  ends  of  the 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  437 

suture  aud  the  incision  in  the  bowel  then  made.  The  incision  should 
not  be  too  large — barely  large  enough  to  permit  introduction  of  the 
half  button  and  should  be  placed  exactly  between  the  two  legs  of  the 
suture.  The  incision  in  the  bowel  is  made  with  the  scissors,  the  wall 
of  the  gut  being  picked  up  with  two  thumb  forceps  to  facilitate  this 
step.  The  two  halves  of  the  button  are  introduced,  one  into  each  loop 
of  the  gut,  and  sutured  by  tying  the  purse-string,  pressed  together 
and  the  operation  thus  completed  (see  Fig.  203).  This  is  a  com- 
paratively simple  method  of  doing  a  lateral  intestinal  anastomosis. 
One  of  the  stitch  methods,  however,  is  preferable. 

With  McGraw's  Eubber  Suture. — With  the  rubber  suture  a 
lateral  intestinal  anastomosis  may  be  conveniently  made  and  with 
very  good  result  in  a  manner  analogous  to  that  described  for  the 
gastro-jejunostomy.  The  surfaces  of  the  two  segments  of  gut  that 
are  to  be  joined  are  placed  side  by  side  and  united  for  a  distance  of 
about  two  and  one-half  inches  with  a  continuous  Lembert  stitch  of 
silk  as  described  in  the  previous  operation,  and  then  the  needle  carry- 
ing this  stitch  is  temporarily  laid  aside.  The  rubber  suture,  2  to  3 
mm.  thick,  is  introduced  with  a  straight  needle  so  as  to  include  both 
segments  of  the  gut  in  its  grasp,  is  drawn  tight,  and  tied.  A  silk 
ligature  is  tied  around  the  knot  in  the  rubber  suture  so  as  to  secure 
the  latter  from  slipping.  About  two  inches  of  the  length  of  each 
segment  of  the  gut  should  be  included  in  the  constricting  rubber 
suture;  so  that,  when  this  cuts  through,  the  opening  left  between  the 
two  coils  of  gut  will  be  two  inches  in  length  (see  "Gastro-jejunostomy 
with  McGraw's  Eubber  Suture").  The  needle,  still  carrying  the  silk 
thread  and  which  was  temporarily  laid  aside,  is  again  taken  up,  and 
with  this  the  two  coils  of  gut  are  united  along  a  line  just  in  front  of 
the  rubber  suture.  This  forms  the  second,  the  anterior  half  of  the 
"outside  serous  ring"  suture,  and  buries  the  rubber  suture  beneath  it 
out  of  sight. 

Gastro-enterostomy. — Gastro-enterostomy  is  the  formation  of  an 
artificial  communication  between  the  stomach  and  the  small  intestine. 
The  anastomosis  may  be  made  between  the  stomach  and  duodenum 
(gastro-duodenostomy)  or  between  the  stomach  and  jejunum  (gastro- 
jejunostomy). 

The  opei-ation  has  for  its  prime  object  the  establishment  of  a 
sufficiently  free  exit  for  the  escape  of  the  stomach  contents ;  for 
stenosis  of  the  pylorus,  whether  simple  and  due  to  non-malignant 
chronic  ulcer  or  the  result  of  malignant  disease;  for  hour-glass  cica- 
tricial contraction   of  the   stomach;   for  the   relief  of   symptoms  of 


438  ABDOMEX  AND  BACK. 

chronic  ulcer  and  chronic  gastritis;  dilatation  consecutive  to  pjdoric 
stenosis,  etc. ;  gastro-jejunostomy  is  performed  for  chronic  ulcer  of 
the  duodenum  with  the  object  of  diverting  the  acid  stomach  contents 
from  this  i^ortion  of  the  bowel. 

G-astro-duodenostomy. — The  anastomosis  is  made  between  the 
stomach  and  duodenum.  This  operation  is  illustrated  in  the  method 
of  implanting  the  end  of  the  stump  of  the  duodenum  into  the  posterior 
wall  of  the  stomach  after  resection  of  the  pylorus,  etc.,  and  in  the 
operation  of  Finney,  described  as  "Pyloroplasty,"  but  which  is  in 
reality  a  gastro-duodenostomy,  and  in  the  gastro-duodenostomy  of 
Kocher. 

Gastro-duodenostomy  (Kocher). — After  the  abdomen  has  been 
opened,  incision,  etc.,  described  in  detail  in  "Gastro-jejunostomy," 
the  duodenum  is  sought  and  mobilized  to  such  a  degree  that  it  can 
be  brought  over  toward  the  middle  line  into  convenient  apposition 
with  the  pyloric  portion  of  the  stomach. 

In  order  to  effect  the  mobilization  of  the  duodenum  it  is  necessary 
to  incise  the  parietal  peritoneum  just  to  the  outer  side  of  and  parallel 
with  the  descending  portion  of  the  duodenum.  The  incision  is  placed 
a  thumb's  breadth  to  the  right  of  the  descending  portion  of  the  duo- 
denum, exposing  the  anterior  surface  of  the  right  kidney.  The 
incision  is  carried  downward  for  a  short  distance  into  the  commence- 
ment of  the  transverse  mesocolon,  which  is  held  taut.  Care  must  be 
exercised  not  to  divide  the  large  arterial  branches  in  the  transverse 
mesocolon. 

The  finger  is  introduced  into  the  incision  in  the  peritoneum  and, 
working  inward  Ijehind  the  duodenum,  this  j)art  of  the  gut,  together 
with  the  head  of  the  pancreas,  is  carefull}^  separated  from  the  surface 
of  the  kidney  and  verteljral  column  and  lifted  upon  the  finger,  foi'ward 
into  the  incision  and  over  toward  the  middle  line  in  order  to  meet  the 
pyloric  portion  of  the  stomach.  A  finger  is  hooked  behind  the  pyloric 
portion  of  the  stomach  and  this  part  likewise  drawn  forward  into  the 
incision. 

A  fold  of  the  wall  of  the  duodenum  and  a  fold  of  the  stomach  wall 
are  secured  with  two  rubber-sheathed  anastomosis-  clamps  which  are 
held  side  by  side  and  the  anastomosis  accomplished  in  a  manner  similar 
to  that  described  in  "Gastro-jejunostomy  with  Clamps,"  "Lateral 
Anastomosis  with  Clamps,"  etc.  The  opening  between  the  duodenum. 
and  stomach  should  be  at  least  one  and  one-half  inches  long. 

According  to  Kocher  this  operation  has  many  advantages  and 
gives  very  satisfactory  remote  results  in  cases  of  pyloric  stenosis. 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


439 


Fig.  2  ;  —  ■  ,  ro-duodenostomy  (Kocher).  The  duodenum  has  been  mobilized 
and  hooked  up  upon  the  finger.  A  finger  of  the  other  hand  is  hooked  in  behind 
the  pylorus.  Both  these  parts  are  approximated  preparatory  to  making  the 
anastomosis  between  them. 


440  ABDOMEN  AND  BACK. 

Gastro-jejunostomy.- — The  junction  is  made  between  the  stomach 
and  jejunum.  This  operation  was  first  performed  by  Woelfier  in  1881. 
The  loop  of  small  intestine  may  be  fixed  to  either  the  anterior  or  the 
posterior  wall  of  the  stomach. 

Anteeior  G-ASTRO-JEJUisrosTOMY  (Woelfler). — This  consists  in 
bringing  a  coil  of  the  small  intestine — jejunum — ^up  in  front  of  the 
great  omentum  and  transverse  colon,  fixing  it  to  the  anterior  wall  of 
the  stomach  and  establishing  a  communication  between  the  two  organs. 
The  anterior  gastro-jejunostomy  is  only  resorted  to  when  for  some 
reason  or  other  it  is  impossible  or  inadvisable  to  do  the  posterior 
operation.  If  the  posterior  wall  of  the  stomach  were  involved  in  the 
disease  or  fixed  by  adhesions  to  the  pancreas,  or  if  a  very  short  trans- 
verse mesocolon  were  encountered,  the  anterior  gastro-jejunostomy 
would  be  indicated.  The  operation  may  be  done  with  suture,  clamps, 
Murphy  button,  or  MbGraw  rubber  ligature. 

The  stomach  should  be  washed  out  with  the  stomach  tube  just 
before  commencing  the  operation,  before  the  patient  is  anaesthetized. 

SuTUEE  Method. — An  incision  is  made  in  the  middle  line  through 
the  linea  alba  from  a  point  one  inch  below  the  ensiform  cartilage  down 
to  the  umbilicus,  or  even  beyond  this  point  if  necessary.  It  is  prefer- 
able as  a  rule  to  make  this  incision  a  little  to  the  left  of  the  middle 
line,  penetrating  between  the  fibers  of  the  rectus  muscle  or,  better, 
after  the  anterior  layer  of  the  sheath  of  the  rectus  has  been  incised 
the  inner  edge  of  the  muscle  is  seized  and  drawn  outward  away 
from  the  middle  line;  the  posterior  layer  of  the  sheath  of  the  rectus 
is  thus  exposed  and  it  and  the  fascia  transversalis  and  the  peritoneum 
are  incised  on  a  line  directly  behind  the  incision  in  the  anterior  layer 
of  the  sheath  of  the  rectus.  Through  this  opening  the  stomach  is 
sought  and  examined. 

After  the  stomach  has  been  recognized  the  transverse  colon,  and 
with  it  the  great  omentum,  is  drawn  out  of  the  incision  and  search  is 
then  made  for  the  commencement  of  the  jejunum.  This  part  of  the 
gut  lies  in  the  back  of  the  abdominal  cavity,  to  the  left  of  the  vertebral 
column,  upon  a  level  with  the  body  of  the  second  lumbar  vertebra,  its 
mesentery  being  very  short  and  serving  to  anchor  it  in  this  position. 
To  secure  this  coil  of  gut  the  hand  is  introduced  into  the  abdomen  and 
carried  backward,  along  the  under  surface  of  the  transverse  mesocolon 
as  far  as  the  posterior  abdominal  wall ;  just  below  the  attachment  of 
the  transverse  mesocolon  to  the  vertebral  column,  at  the  place  indicated 
upon  the  left  of  the  column,  the  coil  of  gut  is  found.    This  part  of  the 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  44I 

small  intestine  is  readily  identified  by  the  fact  that  it  is  fixed  within 
the  abdomen,  as  is  demonstrated  when  an  effort  is  made  to  draw  it  out 
of  the  abdomen :  any  other  part  of  the  small  intestine  may  be  freely 
drawn  through  the  fingers  in  either  direction,  and  may  be  readily 
drawn  out  through  the  incision  upon  the  abdomen. 

A  loop  of  gut  about  eighteen  inches  distant  from  the  commence- 


Fig.  205. — Anterior  Gastro-jejunostomy.  Suture  Method.  The  jejunum  has 
been  united  to  the  anterior  wall  of  the  stomach.  The  posterior  half  of  the  non- 
penetrating "outside  serous  ring"  suture  has  been  introduced.  The  stomach 
and  intestine  have  been  incised. 

ment  of  the  jejunum  is  selected  for  attachment  to  the  stomach.  About 
ten  inches  of  this  loop  of  gut  is  drawn  out  through  the  abdominal 
incision  and  surrounded  for  the  purpose  of  constricting  its  lumen  by 
two  pieces  of  narrow  tape.  The  tapes  are  carried  aromid  the  gut 
with  a  sharp-nosed  artery  forceps  which  is  thrust  through  the  mesen- 
tery close  to  its  attachment  to  the  intestine,  and  with  this  the  end  of 
the  tape  is  seized  and  drawn  through.     The  one  piece  of  tape  is  tied 


443  ABDOMEN  AND  BACK. 

and  the  segment  of  gut  emptied  of  its  contents  to  a  point  beyond  the 
second  piece  of  tape  by  gently  stripping  it  l^etween  the  fingers  and  then 
the  second  tape  is  tied.  The  tapes  should  be  tied  just  sufficiently 
tight  to  prevent  the  re-entrance  of  the  intestinal  contents  into  the 
segment  of  gut.  After  the  coil  of  gut  has  been  secured  and  the  tapes 
applied,  the  transverse  colon  and  great  omentum  are  pushed  back  into 
the  abdomen  and  the  anterior  wall  of  the  stomach  seized  and  drawn 
out  of  the  abdomen.  Dry,  sterile,  gauze  pads  are  placed  about  the 
stomach  and  intestine  and  tucked  partly  into  the  incision  for  the 
purpose  of  retaining  the  parts  outside  the  abdomen  and  to  prevent 
the  entrance  into  the  peritoneal  cavity  of  any  material  that  might 
escape  from  the  stomach  or  intestine. 

The  coil  of  intestine  and  the  stomach  are  steadied,  side  by  side, 
and  united  with  a  continuous  Lembert  suture  of  fine  silk,  using  a 
straight  cambric  needle.  This  suture  line,  which  includes  the  serous 
and  muscular  coats,  forms  the  posterior  half  of  the  "outside  serous 
ring.""  Each  stitch  takes  a  good,  deep,  broad  bite,  but  should  not  pene- 
trate into  the  cavity  of  the  stomach  or  intestine.  The  suture  is 
applied  in  a  straight  line  two  and  one-half  to  three  inches  long;  the 
stitches  are  about  one-eighth  inch  apart  and  each  should  be  drawn 
fairly  tight.  The  tail  of  the  suture  is  left  long  and  may  be  held  by 
the  assistant  as  a  tractor.  After  this  line  of  suture  has  been  completed, 
the  needle  carrying  the  thread  is  laid  aside  temporarily  until  needed 
later  to  complete  the  operation  by  making  the  anterior  half  of  the 
"outside  serous  ring^'  suture.  The  intestine  is  joined  to  the  stomach 
along  a  line  running  obliquely  from  above  downward  and  toward  the 
right.  The  incisions  in  the  intestine  and  stomach  are  next  made. 
They  are  two  to  two  and  one-half  inches  long.  They  are  shorter  than 
the  line  of  the  Lembert  suture  and  should  be  placed  about  one-fourth 
inch  distant  from  it.  They  should  be  straight,  parallel  with  the  line 
of  suture,  and  clean  cut.  The  intestine  is  incised  first.  The  wall  of 
the  gut  is  picked  up  with  two  toothed  forceps  and  a  small  opening 
made  between  these  with  a  straight,  sharp  scissors  and  then  the  open- 
ing thus  made  is  suifieiently  enlarged.  Any  escaping  contents  are  care- 
fully caught  with  gauze  wipes.  The  stomach  is  incised  in  a  similar 
manner.  The  redundant  edges  of  the  mucous  membrane  which  pro- 
trude through  the  incisions  in  the  intestine  and  stomach  are  trimmed 
away  with  the  scissors.  Hemorrhage  from  the  edges  of  the  incisions 
stops  after  they  have  been  sutured ;  any  spurting  points  may  be 
clamped,  however,  and  tied  with  fine  catgut. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  443 

The  corresponding  edges  of  the  incisions  in  the  intestine  and 
stomach  are  sewed  to  each  other  with  catgut  in  a  medium-sized, 
straight  needle,  each  stitch  taking  a  good  hite  and  passing  through  all 
the  coats,  including  the  mucous  membrane,  and  drawn  fairly  tight ; 
the  needle  punctures  should  be  rather  less  than  one-fourth  inch  apart. 
This  suture  is  continued  uninterrupted  all  around,  uniting  the  cor- 
responding edges  of  the  incisions  in  the  stomach  and  intestine  to  each 
other  until  these  openings  are  entirely  closed  in  and  the  anastomosis 
made.  Before  beginning  this  stitch  the  margins  of  the  openings  are 
wiped  with  a  swab  moistened  in  hot  saline  solution. 

After  the  edges  of  the  openings  in  the  stomach  and  jejunum  have 
been  united  all  around,  we  again  take  up  the  first  needle  carrying  the 
silk  thread  with  which  the  posterior  half  of  the  Lembert  suture — "out- 
side serous  ring" — ^was  made  and  complete  the  operation  by  making 
the  anterior  half  of  the  "outside  serous  ring"  suture. 

When  the  operation  has  been  completed  we  have  the  openings  in 
the  intestine  and  stomach,  two  to  two  and  one-half  inches  long,  united 
edge  to  edge,  all  around,  by  a  continuous  stitch  which  passes  through 
the  entire  thickness  of  the  margins  of  the  openings  and  this  sur- 
rounded, reinforced,  by  a  continuous  Lembert  suture  which  passes 
through  the  serous  and  muscular  coats  only,  and  which  serves  the 
purpose  of  burying  the  penetrating  mucous  stitch.  Should  there  be 
any  doubtful  points  where  the  mucous  penetrating  stitch  is  not  cer- 
tainly buried,  one  or  more  supplementary  interrupted  Lembert  stitches 
may  be  taken  to  remedy  this. 

It  will  be  observed  that  the  coil  of  gut  is  joined  to  the  anterior 
wall  of  the  stomach  along  an  oblique  line  running  from  above  down- 
ward and  toward  the  right,  the  lower  end  of  the  line  being  at  the 
greater  curvature,  the  upper  end  pointing  upward  and  toward  the  left, 
toward  the  cardia.  The  gut  is  joined  to  the  stomach  in  such  a  way 
that  the  current  of  food  in  the  stomach  and  in  the  loop  of  intestine 
will  be  in  the  same  direction — the  distal  limb  of  the  loop  of  gut 
toward  the  right  or  pyloric  end  of  the  stomach  ;  this  is  accomplished 
by  taking  care  not  to  twist  the  loop  of  intestine  upon  itself  when  draw- 
ing it  up  into  apposition  with  the  stomach. 

The  transverse  colon  and  great  omentum  rolled  upon  itself  Ho 
together  behind  the  junction  formed  between  the  jejunum  and  the 
stomach. 

The  constricting  tapes  are  finally  removed  from  the  intestine  and 
the  parts  mopped  off  with  a  swab  wet  in  hot  saline  solution  and 
replaced  within  the  abdomen  and  the  abdominal  incision  closed. 


444  ABDOMEN  AND  BACK. 

Clamp  Method. — The  anterior  gastro-jejunostomy  may  be  per- 
formed with  great  facility  with  the  assistance  of  the  holding  clamps. 
The  technique  is  similar  to  that  described  in  detail  in  "Posterior 
Gastro-jejunostomy,  Clamp  Method."  A  fold  of  the  anterior  wall  of 
the  stomach  is  secured  between  the  blades  of  the  clamp  along  a  line 
three  to  four  inches  in  length  and  running  obliquely  from  above  down- 
ward and  toward  the  right,  the  lower  end  of  the  fold  corresponding 
to  the  most  dependent  part  of  the  greater  curvature.  The  commence- 
ment of  the  jejunum  is  sought  for  and  recognized  in  the  manner 
already  described  (see  page  440),  and  a  coil  about  eighteen  inches 
beyond  this  point  is  secured  and  drawn  out  through  the  abdominal 
incision.  A  fold  of  the  wall  of  this  coil  of  gut  similar  in  length  to  that 
of  the  stomach  wall  is  secured  between  the  blades  of  the  holding  for- 
ceps. Doyen,  Moynihan  or  Scudder  clamps  are  used  for  this  purpose. 
The  blades  are  sheathed  with  rubber  tubing  and  grasp  the  wall  of 
stomach  just  tightly  enough  to  secure  it  from  slipping,  but  not  so 
tightly  as  to  damage  or  crush  it.  The  blades  of  the  clamps  holding 
the  fold  of  the  wall  of  the  stomach  and  that  of  the  wall  of  the 
jejunum  are  placed  side  by  side  and  the  anastomosis  made  between 
them  as  described  in  detail  in  "Posterior  Gastro-jejunostomy,  Clamp 
Method,"  page  450. 

Anterior  gastro-jejunostomy  may  be  also  made  with  the  McGraw 
Eubber  Ligature,  Murphy  Button,  etc.  Details  of  the  application  of 
these  methods  are  described  under  "Posterior  Gastro-jejunostomy."_ 

Jaboulay  and  Braun  Modification. — In  some  cases,  after  the 
anterior  gastro-jejunostomy  as  described  above  has  been  performed, 
there  occurs  an  accumulation  of  food,  bile,  and  pancreatic  juice  in  the 
short  (proximal)  limb  of  the  loop  of  the  intestine  that  is  fixed  to  the 
stomach,  with  a  consequent  regurgitation  into  the  stomach,  and  this 
is  characterized  by  exhausting  and  fatal  vomiting.  The  regurgitation 
and  vomiting  are  due  to  a  spur  formation  at  the  point  where  the  coil 
of  gut  is  attached  to  the  stomach.  The  spur  directs  the  stomach  con- 
tents into  the  short  or  proximal  arm  of  the  gut,  which  becomes  dis- 
tended and  with  the  result  that  the  contents  back  up  and  overflow  back 
into  the  stomach.  In  order  to  avoid  the  occurrence  of  this  vomiting — 
"vicious  circle" — a  lateral  communication  is  made  between  the  two 
limbs  of  the  coil  of  intestine  which  has  been  attached  to  the  stomach. 
This  may  be  done  either  at  the  same  time  that  the  gastro-jejunostomy 
is  performed,  or,  since  this  regurgitation,  etc.,  do  not  occur  in  all  cases, 
it  may  be  done  later  as  a  secondary  operation,  waiting  for  the  appear- 
ance of  symptoms  indicating  the  necessity  of  the  additional  operation 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


445 


before  submitting  the  patient  to  the  additional  risk.  It  is  probably 
«'ise  to  do  this  entero-anastomosis  at  the  same  time  as  the  primary 
gastro-jejunostomy,  as  it  occupies  but  a  few  minutes'  additional  time. 
The  secondary  entero-anastomosis  may  be  made  with  suture,  clamps, 
Murphy  button,  or  McGraw's  rubber  suture,  etc.     The  communicatioa 


Fig.  206. — Jaboulay  and  Braun  Modification.  A  lateral  anastomosis  has  been 
established  between  the  two  arms  of  the  loop  of  jejunum.  The  arrow  indicates 
the  opening  through  which  contents  may  escape  from  one  arm  of  the  gut  into 
the  other. 

between  the  two  limbs  of  the  loop  of  gut  should  be  made  at  their  most 
dependent  part. 

For  the  details  of  the  operation  of  lateral  intestinal  anastomosis 
with  the  simple  suture,  clamps,  McGraw  rubber  ligature,  etc.,  the 
reader  is  referred  to  the  description  of  these  various  procedures  as 
thev  are  given  elsewhere  in  this  volume. 


446  ABDOMEN  AND  BACK. 

Posterior  Gastro-jejunostomy  (von  Hacker). — The  jejunum 
is  sutured  to  the  posterior  wall  of  the  stomach,  which  is  made  access- 
ible through  an  opening  torn  in  the  transverse  mesocolon.  As 
originan}^  employed  a  loop  of  the  jejunum,  twelve  to  fourteen  inches 
from  its  commencement,  was  anastomosed  to  the  stomach.  The 
operation  was  followed  in  man}^  cases  by  the  phenomena  of  the 
"vicious  circle" :  regurgitation,  exliaustive  vomiting,  and  a  fatal 
termination.  It  is  most  desirable  to  eliminate  the  loop  arrange- 
ment of  the  anastomosed  gut,  and  this  is  accomplished  by  using 
the  uppermost  portion  of  the  jejunum,  within  a  few  inches  of  its 
commencement  at  the  duodeno-jejunal  junction,  for  the  purpose  of 
establishing  the  anastomosis  with  the  stomach.  This  highest  por- 
tion of  the  jejunum  is  situated  normally  just  behind  the  stomach, 
close  to  its  posterior  wall,  separated  from  it  by  the  interposed  trans- 
verse mesocolon  only.  It  may  be  readily  attached  to  the  posterior 
wall  of  the  stomach  after  an  opening  has  been  made  in  the  transverse 
mesocolon.  The  posterior  gastro-jejunostomy  without  a  loop  is  the 
preferable  operation  in  all  cases  where  it  is  feasible,  reserving  the 
anterior  gastro-jejunostomy  for  those  cases  that  offer  some  counter- 
indication  or  impediment  as  disease  of  the  posterior  wall  of  the 
stomach,  adhesions  to  the  pancreas,  abnormally  short  transverse  meso- 
colon, etc.  The  operation  may  be  performed  with  suture,  clamps, 
Murphy  button,  McGraw  rubber  ligature,  etc. 

Posterior  Gastro-jejunostomy  Without  a  Loop,  Suture 
Method. — An  incision  is  made  in  the  middle  line  or  the  incision  may 
be  placed  a  little  to  the  left  of  the  middle  line,  penetrating  between 
the  iibers  of  the  rectus  muscle,  or  the  muscle  may  be  displaced  outward, 
as  described  in  the  preceding  paragraphs.     (See  page  440.) 

After  the  stomach  has  been  recognized  the  transverse  colon 
and  great  omentum  are  drawn  out  upon  the  abdomen  and  reflected 
upward.  In  order  to  expose  the  posterior  wall  of  the  stomach  a 
small  opening  is  cut  or,  better,  torn  in  the  transverse  mesocolon, 
selecting  a  part  which  is  devoid  of  blood-vessels.  This  opening  is 
enlarged  with  the  fingers  until  it  is  sufficiently  large  to  accommo- 
date three  or  four  fingers.  Care  must  be  exercised  not  to  injure 
any  blood-vessels,  particularly  the  arteria  colica  media,  in  making 
the  opening  in  the  transverse  mesocolon.  The  posterior  wall  of  the 
stomach  is  drawn  partly  through  the  opening  which  has  been  thus 
made  in  the  transverse  mesocolon,  and  the  edges  of  the  opening  in 
the  transverse  mesocolon  fixed  at  once  to  the  posterior  wall  of  the 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


447 


0.2 


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448  ABDOMEN  AND  BACK. 

stomach  by  several  sutures  of  fine  silk.  These  sutures  do  not  pierce 
the  entire  thickness  of  the  stomach  wall.  They  penetrate  the  serous 
and  muscular  coats  only.  The  exposed  area  of  the  stomach  wall 
which  presents  through  the  opening  in  the  transverse  mesocolon  is 
then  brought  out  through  the  incision  in  the  abdomen,  where  it  is 
retained  by  an  assistant. 

As  already  described  in  the  preceding  operations,  the  com- 
mencement of  the  jejunum  is  found  in  the  back  of  the  abdomen 
to  the  left  of  the  body  of  the  second  lumbar  vertebra,  just  below 
the  vertebral  attachment  of  the  transverse  mesocolon.  This  coil 
of  gut  is  secured  and  brought  up  into  the  abdominal  incision.  The 
portion  of  gut  which  is  thus  secured  for  attachment  to  the  posterior 
wall  of  the  stomach  corresponds  to  the  upper  five  inches  of  the 
jejunum.  The  coil  of  gut  is  stripped  between  the  fingers  to  empty 
it,  and  a  piece  of  narrow  tape  is  passed  around  it  ten  or  twelve 
inches  farther  along,  away  from  its  commencement.  The  tape  is 
drawn  through  the  mesentery  with  a  sharp-nosed  artery  clamp  which 
is  thrust  through  the  mesentery  close  to  the  gut.  The  tape  is  tied 
just  sufficiently  tight  to  prevent  the  re-entrance  of  contents  into 
the  coil  of  gut  which  has  been  emptied.  The  transverse  colon  and 
great  omentum  are  pushed  back  into  the  abdomen.  Pads  of  gauze 
are  tucked  about  the  viscera  and  partly  into  the  abdominal  incision 
to  steady  the  parts  and  to  prevent  the  entrance  of  material  from 
the  stomach  or  intestine  into  the  peritoneal  cavity,  and  the  gastro- 
jejunostomy is  then  performed  in  a  manner  similar  to  that  already 
described  in  detail  in  "Anterior  Gastro-jejunostomy,  Suture  Method.'" 
The  intestine  is  fixed  to  the  posterior  wall  of  the  stomach  with  a 
Lambert  suture  along  an  oblique  line  for  a  distance  of  two  and  one- 
half  to  three  inches,  and  reaching  from  the  lowest  part  of  the 
greater  curvature  upAvard  and  to  the  left — pointing  toward  the 
cardia.  The  stomach  and  intestine  are  incised.  The  incisions,  two 
to  two  and  one-half  inches  long,  are  made  parallel  with  and  about 
one-quarter  inch  distant  from  the  line  of  the  Lembert  suture.  The 
redundant  edges  of  mucous  membrane  that  protrude  through  the 
incisions  are  trimmed  away  Avith  the  scissors.  The  incisions  are 
shorter  than  the  line  of  Lembert  suture  that  joins  the  jejunum  to 
the  stomach.  The  corresponding  edges  of  t]ie  openings  in  the  stom- 
ach and  intestine  are  sewed  together  all  around  with  a  through-and- 
through  stitch  of  chromic  catgut,  finally  completing  the  operation 
by   introducing   the    anterior   half   of   the    Lembert    "outside    serous 


Fig.  208. — Posterior  Gastro-jejunostomy  Without  a  Loop  (Czenu/).  The  upper 
part  of  the  jejunum  is  situated  normally  behind  the  stomach.  The  arrow  indi- 
cates the  anastomosis  between  the  posterior  wall  of  the  stomach  and  the  upper 
part  of  the  jejunum.  C,  colon;  GO,  great  omentum;  J,  jejunum;  P,  pancreas; 
iS,  symphysis  pubis. 

29 


450  ABDOMEN  AND  BACK. 

ring"  suture,  with  the  needle  and  thread  which  were  used  for  the 
first  half  of  the  Lembert  suture. 

When  the  operation  has  been  completed  it  will  be  observed 
that  the  uppermost  part  of  the  jejunum  (within  the  first  five  inches 
of  its  commencement)  is  attached  to  the  posterior  wall  of  the 
stomach  along  a  line  running  obliquely  from  above  downward  and 
toward  the  right,  the  lower  end  of  the  line  corresponding  to  the 
lowest  point  of  the  greater  curvature,  and  the  iipper  end  pointing 
toward  the  cardia.     Mayo  recommends  that  the  line  of  attachment 


F'ig.  209. — Posterior  Gastro-jejunostomy.  Shows  the  line  of  attachment  of 
jejunum  to  the  stomach  running  obliquely  from  above  downward  and  toward 
the  right. 

of  the  jejunum  to  the  stomach  be  reversed — i.e.,  run  obliquely  from 
right  to  left  and  from  above  downward,  beginning  one  inch  above 
the  greater  curvature  on  a  line  prolonged  downward  from  the  longi- 
tudinal portion  of  the  lesser  curvature,  and  ending  at  the  bottom 
of  the  stomach  two  and  one-half  inches  to  the  left.  This  line  of 
attachment  avoids  reversion,  bending,  of  the  anastomosed  coil  of 
gut  at  the  point  where  it  is  attached  to  the  stomach. 

Clamp  Method. — After  the  abdomen  has  been  opened  as  already 
described  in  the  preceding  paragraphs,  the  stomach  is  drawn  out 
through  the  opening  which  is  made  in  the  transverse  mesocolon. 
The  lowest  point  of  the  greater  curvature  of  the  stomach,  as  it 
lies  in  its  natural  position,  is  previously  located  and  fixed  for  identi- 


Fig.  210. — Posterior  Gastro-jejunostomy,  Clamp  Method.  An  opening  torn 
in  the  transverse  mesocolon  and  a  fold  of  the  posterior  wall  of  the  stomach 
secured  between  the  blades  of  the  holding  forceps.  The  edges  of  the  opening 
In  the  transverse  mesocolon  have  been  fixed  to  the  wall  of  the  stomacli  with 
several  sutures. 


Fig.  211. — Gastro-jejunostomy,  Clamp  Method.  The  folds  of  the  wall  of 
the  stomach  and  jejunum  in  the  grasp  of  the  holding  clamps.  The  two  folds 
have  been  joined  together  with  the  non-penetrating  suture — the  posterior  half 
of  the  "outside  serous  ring"  suture. 


452  ABDOMEN  AXD  BACK. 

fication  by  the  tlinmb  and  finger  of  the  left  hand  in  order  to  mark 
tlie  lower  end  of  the  fold  of  the  stomach  wall  that  is  to  be  grasped 
between  the  blades  of  the  clamp.  Eeaching  obliquely  upward  and 
toward  the  left  from  this  point  on  the  greater  curvature,  toward 
the  cardia,  a  fold  of  the  stomach  wall  three  and  one-half  to  four 
inches  in  length  is  secured  between  the  blades  of  the  clamp.  A 
holding  clamp  with  elastic  blades  after  the  pattern  of  Doyen, 
Moynihan,  Scudder,  with  the  blades  sheathed  with  rubber  tubing, 
is  used  for  this  purpose.  The  clamp  is  applied  with  the  operator 
standing  upon  the  patient's  left  side;  the  tip  of  the  clamp  as  it 
grasps  the   fold  of   the   posterior  wall   of   the   stomach   is   directed 


Fig.  212. — Posterior  Gastro-jejunostomy.  Shows  tlie  line  of  attachment  of 
the  jejunum  to  the  stomach  running  obliquely  from  above  downward  and 
toward  the  left  (Mayo). 

upward  toward  the  patient's  right  shoulder — the  handles  toward 
the  patient's  left  side. 

The  commencement  of  the  jejunum  is  next  sought.  It  is 
found  lying  to  the  left  of  the  body  of  the  second  lumbar  vertebra 
(see  page  440).  A  fold  of  the  wall  of  the  uppermost  part  of  this 
portion  of  the  intestine,  similar  in  length  to  that  of  the  stomach 
wall,  is  grasped  between  the  blades  of  the  clamp.  The  fold  of 
intestine  should  be  taken  in  the  upper  five  or  six  inches  of  the 
jejunum  and  along  a  line  opposite  its  mesenteric  border. 

The  two  clamps  holding  the  folds  of  stomach  and  jejunum  are 
placed  side  by  side  so  that  they  lie  transversely  across  the  incision 
in  the  abdomen  and  the  transverse  colon,  great  omentum,  are 
replaced  back  in  the  abdominal  cavity.    The  folds  of  the  stomach  and 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


453 


Fig.  213.— Gastro-jejunostomy,  Clamp  Method.  The  folds  of  stomach  and 
jejunum  have  been  incised  down  to  the  mucous  layer.  The  edges  of  the  inci- 
sions retract,  exposing  an  elliptical  area  of  the  mucous  layer,  which  is  excised 
with  the  sharp-pointed  scissors. 


Fig.  214.— Gastro-jejunostomy,  Clamp  Method.  The  edges  of  the  incisions 
in  the  stomach  and  the  jejunum  are  united  all  around  with  an  overhand  con- 
tinuous suture. 


454  ABDOMEN  AXD  BACK. 

•  :^-  i 
jejunum  are  joined  together  with  a  continuous  non-penetrating 
suture  of  silk.  This  suture  picks  up  the  serous  and  muscular  layers, 
commencing  at  the  left  and  working  toward  the  right — toward  the 
tips  of  the  clamps.  The  folds  of  stomach  and  jejunum  are  joined 
for  a  distance  of  two  and  one-half  to  three  inches.  The  stitches 
are  introduced  about  one-eighth  inch  apart  and  each  drawn  fairly 
tight.  After  this  line  of  suture  has  been  introduced  the  needle  is 
temporarily  laid  aside,  the  thread  being  left  long  to  be  used  later 
to  complete  the  outside  serous  ring  suture. 

Incisions  are  made  in  the  stomach  and  intestine.  These  inci- 
sions are  shorter  than  the  suture  line,  two  to  two  and  one-half 
inches  long,  and  are  placed  parallel  with  and  about  one-quarter 
inch  distant  from  the  suture  line.  The  incisions  reach  down 
through  the  serous  and  muscular  coats  only,  exposing  the  mucosa. 
The  incised  serous  and  muscular  coats  retract,  leaving  exposed  an 
elliptical  area  of  the  mucosa  two  to  two  and  one-half  inches  long 
and  one-half  inch  across  at  its  widest  part.  The  exposed  areas  of 
mucosa  of  the  stomach  and  intestine  are  excised  with  a  sharp- 
pointed  scissors. 

After  the  incisions  have  been  made  in  the  stomach  and  intes- 
tine the  parts  are  wiped  clean  with  a  pad  wet  with  saline  solution, 
and  the  corresponding  edges  of  the  openings  sewed  to  each  other 
all  around  with  a  continuous  stitch  of  chromic  catgut  carried  in  a 
medium-sized  needle.  Each  stitch  takes  a  good  bite,  passing 
through  all  the  coats,  especially  the  mucosa,  and  is  drawn  fairly 
tight;  the  needle  thrusts  should  be  rather  less  than  one-quarter 
inch  apart.  This  suture  is  continued  uninterrupted  all  around, 
uniting  the  corresponding  edges  of  the  openings  in  the  stomach  and 
intestine  until  they  are  entirely  closed  in. 

After  the  edges  of  the  openings  have  been  united  all  around 
the  clamps  are  removed  and  the  parts  again  wiped  clean  with 
swabs  wet  in  hot  saline,  and  the  needle  still  carrying  the  silk  thread 
with  which  the  first,  posterior,  half  of  the  non-penetrating  suture, 
"outside  serous  ring,"  was  made,  is  again  taken  up  and  with  it  the 
second,  anterior,  half  of  the  "outside  serous  ring'^  suture  is  intro- 
duced and  the  operation  thus  completed. 

It  will  be  observed  that  the  uppermost  part  of  the  jejunum 
is  attached  to  the  posterior  wall  of  the  stomach  along  an  oblique 
line  running  from  above  downward  and  toward  the  right,  the  lower 
end  of  the  line  corresponding  to  the  lowest  point  of  the  greater 
curvature.      Mayo    advises    attaching    the    jejunimi    to    the    stomach 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  455 

along  an  oblique  line  commencing  one  inch  above  the  greater  curva- . 
ture  on  a  perpendicular  with  the  longitudinal  portion  of  the  lesser 
curvature,  and  terminating  two  and  one-half  inches   to  the  left  at 
the  greater  curvature.     (See  Figs.  209  and  212.) 

The  parts  are  finally  returned  to  the  abdominal  cavity,  the 
stomach  to  its  natural  position,  and  the  transverse  colon  and  greater 
omentum  drawn  down  into  their  normal  position  and  the  incision 
in  the  abdomen  closed. 

Gasteo-jejunostOjMY  with  the  Murphy  Button. — This  is  a 
comparatively  simple  operation  and  much  time  can  be  saved  by 
the  use  of  the  device.  The  button  can  be  used  for  either  the 
anterior  or  posterior  gastro-jejunostomy.  The  MurjDhy  button  is 
much  less  frequently  employed  at  present  than  formerly,  the  suture 
and  the  clamp  methods  being  preferred  by  most  surgeons.  The  use 
of  the  Murphy  button  is  no  doubt  indicated  in  some  cases,  espe- 
cially where  a  malignant  condition  exists  and  the  time  permitted 
for  the  perfonnance  of  the  operation  is  short.  The  medium-size 
button  may  be  used  for  the  gastro-jejunostomy,  and  a  smaller  one 
for  the  entero-anastomosis,  if  this  latter  operation  is  performed  in 
addition. 

If  a  posterior  gastro-jejunostomy  is  made,  the  button,  when 
liberated,  is  less  likely  to  fall  into  the  stomach  than  when  the  ante- 
rior gastro-jejunostomy  is  the  operation  performed.  According  to 
the  suggestion  of  Weir,  the  margin  of  that  half  of  the  button  which 
presents  into  the  intestine  may  be  provided  with  projecting  flanges, 
which  should  hinder  the  button  from  falling  into  the  stomach. 

The  stomach  and  intestine  are  brought  out  upon  the  abdomen 
as  in  the  operations  above  described.  A  purse-string  suture  is  intro- 
duced in  the  wall  of  the  intestine  and  the  wall  of  the  stomach, 
penetrating  through  the  entire  thickness  of  each.  The  space 
included  between  the  two  limbs  of  the  purse-string  suture  should 
be  about  one-half  inch;  for  description  of  the  running,  purse-string 
suture  and  the  method  of  its  introduction  see  "Lateral  Intestinal 
Anastomosis."  This  purse-string  suture  is  applied  first  to  the 
jejunum  and  then  between  the  two  limbs  of  the  suture  line  an 
incision  is  made  into  the  gut;  this  should  be  barely  large  enough 
to  permit  the  introduction  of  the  half  button.  That  half  button 
which  is  provided  with  the  spring  is  seized  with  a  thumb  forceps 
and  introduced  through  the  incision  into  the  gut,  and,  while  it  is 
thus  steadied,  the  purse-string  is  drawn  tight  about  its  shank,  tied, 
and  the  ends  cut  short. 


456  ABDOMEN  AND  BACK. 

In  a  similar  manner,  after  the  purse-string  has  been  applied 
to  the  wall  of  the  stomach,  this  is  incised,  and  the  other  half  of 
the  button  is  introduced  into  this  incision  and  the  string  tied 
about  its  neck.  The  parts  adjacent  to  the  openings  are  wiped  with 
a  pad  wet  with  hot  saline  and  the  two  halves  of  the  button  delib- 
erately pressed  home.  They  should  be  applied  sufficiently  tight 
to  cause  a  gradual  pressure  necrosis  of  those  parts  of  the  walls 
of  the  viscera  that  are  included  within  their  grasp.  If  any  raw 
edge  of  mucous  membrane  is  seen  presenting  between  the  flanges 
of  the  button  it  should  be  seized  with  the  thumb  forceps  and 
trimmed  close  with  sharp  scissors  and  then  be  still  farther  buried 
with  several  additional  Lembert  stitches.  Murphy  claims  that  the 
additional  outside  Lembert  stitch  is,  as  a  rule,  unnecessary;  never- 
theless, it  is  well  to  use  it,  especially  if  there  are  any  doubtful 
points.  The  button  being  in  position,  the  application  of  the  Lem- 
bert stitch  is  easy.  Spurting  vessels  in  the  edges  of  the  openings 
in  the  intestine  and  stomach  may  be  clamped  and  tied  with  fine 
catgut. 

Gastro-jejuxostomt  with  M'cGr.\-w's  Eubber  Suture. — The 
gut  is  brought  into  apposition  with  the  anterior  or  posterior  sur- 
face of  the  stomach,  as  described  in  the  preceding  operations,  and 
these  two  portions  of  the  alimentary  canal  are  joined  to  each  other 
with  a  continuous  silk  Lembert  stitch  for  a  distance  of  two  and 
one-half  inches.  After  this  line  of  suture  has  been  introduced  the 
needle  still  carrying  the  suture  is  temporarily  laid  aside. 

The  stomach  is  then  united  to  the  intestine  with  a  single 
suture  of  solid  rubber,  smooth  and  round  and  from  3  to  5  mm. 
in  thickness.  This  suture  is  carried  in  the  eye  of  a  long,  straight 
needle;  a  large  worsted  needle  or  Hagedorn  needle  answers  well 
for  this  purpose.  It  will  be  necessary  to  shave  the  end  of  the 
rubber  suture  so  that  it  may  enter  the  eye  of  the  needle.  The 
point  of  the  needle  is  passed  into  the  stomach  and  then  out  again, 
so  that  about  two  inches  of  the  wall  of  the  stomach,  corresponding 
to  its  long  diameter,  is  included  between  the  two  punctures.  The 
rubber  suture  is  put  upon  the  stretch  and  the  needle,  pulling  the 
suture  after  it,  is  then  drawn  through.  With  the  same  needle  and 
suture  and  in  a  similar  manner,  the  intestine  is  pierced,  entering 
and  emerging  at  points  opposite  the  puncture  holes  in  the  stomach. 
The  rubber  suture  is  drawn  very  tight,  thus  constricting  the  parts 
included  in  its  grasp,  and  tied.  In  order  to  secure  the  knot  in  the 
rubber  ^suture  a  strand  of  stout  silk  may  be  placed  underneath  the 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


457 


rubber  at  the  place  where  the  knot  is  to  be,  and  after  one  loop 
of  the  knot  has  been  taken  in  the  rubljer  suture  the  silk  ligature 
is  tied  over  it  and  then  the  second,  final  loop  of  the  knot  is  taken 


Fig.  215. — Gastro-jejunostomy  {McOraic).  A  loop  of  intestine  has  been  fixed 
to  the  waU  of  the  stomach  with  a  continuous,  non-penetrating  stitch  (i.,  A). 
Rubber  ligature  (B,  B,  B),  which  has  been  passed  through  the  stomach  and 
intestine,  ready  for  tying. 


in  the  rubber  suture  and  the  silk  ligature  again  tied  over  this.     The 
ends  of  both  rubber  and  silk  ligatures  are  cut  very  short. 

In  passing  the  rubber  suture  one  should  make  certain  that  the 
needle  pierces  the  entire  thickness  of  the  wall  of  the  organ  and 
that  it  does  not  pick  up  the  mucous  membrane  of  the  viscus  on  its 


458  ABDOMEN  AND  BACK. 

wa}^  to  make  the  second  puncture^ — that  of  exit;  in  each  viscus 
there  should  be  two  punctures  only, — one  as  the  needle  passes  in 
and  one  as  the  needle  passes  out.  In  drawing  the  rubber  suture 
after  the  needle,  through  the  wall  of  the  stomach  and  intestine, 
it  may  be  stretched  so  that  it  becomes  thinner,  and  may  thus  the 
more  readily  follow  the  needle  through  the  punctures. 

Finally,  to  complete  the  operation,  the  needle,  carrying  the  silk 
thread  with  which  the  first  half  of  the  Lembert  "outside  serous 
ring'"  suture  was  applied,  is  again  taken  in  hand  and  with  it  the 
wall  of  the  stomach  and  intestine  are  joined  with  a  continuous 
stitch,  which  is  applied  along  a  line  just  in  front  of,  anterior  to, 
the  rabber  ligature,  and  which  buries  this  latter  and  completes  the 
"outside  serous  ring"  suture. 

By  this  operation  corresponding  portions  of  the  apposed  walls 
of  the  stomach  and  the  intestine  are  included  in  the  grasp  of  a 
single,  elastic-rubber  suture,  which,  when  drawn  very  tight,  gradu- 
ally cuts  its  way  through  the  walls  of  the  united  viscera,  with  the 
result  that  after  the  lapse  of  two  days  the  gastro-jejunostomy  is 
established  and  the  liberated  rubber  suture  is  passed  unobserved 
through  the  bowel.  This  plan,  of  operation  may  also  be  employed 
in  making  a  lateral  anastomosis  between  two  coils  of  the  small 
intestine  or  between  the  small  and  large  intestine. 

Posterior  Gastro-jejunostomy,  Y  Method  of  Eoux. — This 
procedure  gives  very  satisfactory  results.  The  phenomena  of  the 
"vicious  circle"  are  not  observed  after  the  operation,  but,  as  a 
matter  of  fact,  considerably  more  time  is  required  for  its  execu- 
tion, especially  at  the  hands  of  surgeons  less  familiar  with  the 
technique  of  intestinal  operations.  The  results  following  the  usual 
method  of  posterior  gastro-jejunostomy  without  a  loop  are  just  as 
good.  Time  is  a  consideration  of  serious  moment  in  intestinal 
operations,  particularly  in  patients  feeble  and  exhausted  from  pro- 
longed inanition, 

A  coil  of  gut  about  20  cm.  distant  from  the  commencement 
of  the  jejunum  is  selected.  The  gut  is  stripped  between  the  fingers 
in.  order  to  empty  it,  and  a  strip  of  narrow  tape  tied  around  the 
gut.  Two  straight  elastic  holding  forceps  are  applied  to  the  gut 
close  together  and  the  intestine  divided  between  them  with  the 
scissors,  the  cut  reaching  into  the  mesentery  as  far  as  the  first 
important  vascular  arch.  The  posterior  wall  of  the  stomach  is 
then  exposed  by  tearing  through  the  transverse  mesocolon,  the 
edges   of  the   opening  in  the  transverse   mesocolon  being   fixed   to 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  459 

the  wall  of  the  stomach  with  several  non-penetrating  silk  sutures. 
The  distal,  lower,  end  of  the  divided  gut  is  lifted  up  and  sewed 
into  an  opening  made  for  the  purpose  in  the  posterior  wall  of  the 
stomach  and  the  proximal  upper,  end  of  the  gut  sutured  into  an 
opening  made  in  the  left  side  of  the  lower,  distal  loop  of  the  gut— 
the  part  that  has  been  sutured  to  the  stomach. 


Fig.  216.— Posterior  Gastro-jejuncstomy  (Roux).  Upper  part  of  jejunum  has 
been  divided  and  the  lower  segment  sutured  into  an  opening  in  the  posterior 
waU  of  the  stomach  through  a  hole  in  the  mesocolon.  The  upper  segment  has 
been  sutured  into  an  opening  in  the  side  of  the  lower  segment. 

The  method  of  uniting  the  ends  of  the  giit  to  the  edges  of 
the  ojDenings  made  in  the  stomach  and  intestine  is  similar  to  that 
employed  in  joining  the  end  of  the  duodenum  to  the  stomach  in 
"Pylorectomy  (Kocher)."  (See  page  391.) 

finally  the  cut  edges  of  the  mesentery  are  sutured  to  the  adja- 
cent underlying  mesocolon  and  mesentery  and  the  operation  thus 
completed. 


460  ABDOMEN  AXD  BACK. 

This  method  provides  very  excellent  drainage  for  the  stomach 
and  eliminates  almost  positively  the  danger  of  regurgitation  and 
"vicious  circle"  phenomena. 

THE    LARGE    INTESTINE    AND    VERMIFORM    APPENDIX. 

The  Surreal  Anatomy  of  the  Large  Intestine,  etc. — The  large 
intestine  may  be  distinguished  from  the  small  intestine  by  its  large 
caliber  and  by  its  sacculation;  attached  along  its  whole  length  is 
the  great  omentum  or  the  analogues  of  this  structure,  the  appen- 
dices epiploicse.  The  large  intestine  is  also  marked  by  three  longi- 
tudinal bands  which  traverse  its  entire  length.  These  longitudinal 
bands  are  made  up  of  an  aggregation  of  the  longitudinal  muscular 
fibers;  one  of  them  is  found  along  the  mesenteric  border  of  the 
gut,  another  corresponds  to  the  attachment  of  the  great  omentum 
and  the  little  fatty  processes,^the  appendices  epiploicte, — and  the 
third  is  located  between  these  two. 

The  large  intestine  may  be  divided  into  three  parts :  the  caecum, 
colon  (ascending,  transverse,  descending,  and  sigmoid  flexure),  and 
the  rectum. 

The  CiECUii  is  the  dilated,  pouched  commencement  of  the  large 
intestine.  It  is  found  in  the  right  iliac  fossa,  near  the  brim  of  the 
pelvis,  resting  upon  the  psoas  or  iliacus  muscle.  It  is  provided  with  a 
complete  peritoneal  investment,  is  movable,  and  has  a  mesentery  which 
is  short  and  serves  to  anchor  it  to  the  posterior  abdominal  wall.  The 
mesentery  is  sufficiently  long  in  the  majority  of  instances,  how- 
ever, to  allow  this  part  of  the  intestinal  canal  to  be  drawn  out 
upon  the  abdominal  wall.  The  layers  of  the  mesocsecum  are  but 
loosely  adherent  to  each  other  and  may  be  readily  separated.  As 
a  result  of  this  loose  arrangement  the  caecum  may  slip  down  from 
within  the  folds  of  its  mesentery  and  escape  into  the  inguinal 
canal  and  form  a  hernia  which  is  only  partly  provided  with  a  sac. 
In  such  a  hernia  when  the  sac  is  opened,  it  will  be  found  that  the 
caecum  is  attached  to  the  interior  of  the  sac  and  cannot  be  sepa- 
rated because  the  mesenteric  folds  of  the  cfecum  are  directly  con- 
tinuous with  the  sac.  The  caecum  cannot,  therefore,  be  independ- 
ently returned  to  the  abdomen.  When  the  caecum  is  returned  into 
the  abdominal  cavity,  the  sac  must  be  returned  in  part  with  it- 
The  CEeeum  is  continued  upward  into  the  ascending  colon  without 
any  definite  line  of  demarcation  between  them. 

The  VERMiFOE]\r  Appendix  is  a  blind,  worm-like  process,  which 
is  given  off  from  the  inner  posterior  aspect  of  the  cfecum  at  the 


SURGICAL  AXATOMY  OF  THE  LARGE  IXTESTINE.  401 

j)oint  where  the  longitudinal  bands  ^meet  and  from  one  to  one  and 
one-half  inches  below  the  junction  of  the  small  intestine  with  the 
cfficum.  It  is  found  lying  more  or  less  free  in  the  abdominal  cavity 
or  dipping  into  the  pelvis. 

The  base  of  the  appendix  corresponds  to  a  point  on  the  abdomi- 
nal wall  called  "McBurney's  point,"^'  which  is  located  two  inches  to- 
the  inner  side  of  the  anterior  superior  iliac  spine,  upon  a  line  drawn 
from  the  anterior  superior  iliac  spine  to  the  umbilicus. 

The  appendix  varies  much  in  size;  it  is  usually  as  thick  around 
as  a  lead  pencil  and  its  average  length  is  four  inches;  it  varies  from 
two  to  six  inches  and  may  be  longer.  Usually  it  is  a  hollow  tube, 
its  canal  extending  as  far  as  its  tip;  at  times,  hoAvever,  the  canal 
does  not  extend  to  the  tip  or  may  be  absent  entirely.  Its  inner 
surface  is  lined  with  mucous  membrane.  The  appendix  is  an  intra- 
peritoneal structure,  being  completely  invested  by  the  peritoneum, 
and  in  nearly  all  cases  it  is  provided  with  a  mesentery  of  its  own. 
This  mesentery  is  a  little  fold  derived  from  the  under  layer  of  the 
mesentery  of  the  small  intestine  where  the  latter  enters  the  cax-imi; 
it  incloses  the  appendix  between  its  folds,  and  usually  extends  only 
part  way  down  to  the  tip,  leaving  the  lower  third  or  half  of  the 
appendix  free.  This  mesentery  gives  one  the  impression  of  being 
too  short,  causes  the  appendix  to  present  its  curled-up  appearance, 
serves  to  limit  its  range  of  movement,  and  holds  it  in  close  relation 
with  the  caecum.  That  part  of  the  appendix,  toward  the  tip,  which 
is  unprovided  with  mesentery  is  freely  movable.  In  most  cases  the 
appendix  is  more  or  less  fixed  to  the  caecum  and  to  the  posterior 
abdominal  wall  through  its  mesentery.  Its  position,  as  regards  the 
caecum,  varies  in  different  individuals;  most  commonly  it  is  foitnd 
lying  upon  the  inner  or  left  side  of  the  caecum,  with  its  tip  behind 
the  ileum  and  pointing  upward  in  the  direction  of  the  spleen.  In 
other  cases  it  lies  ti^^on  the  outer  or  right  side  of  the  caBcuni,  rather 
behind  it.  its  tip  pointing  upward  toward  the  liver;  again,  it  may 
be  found  dipping  down  into  the  pelvis  or  lying  across  the  front  of 
the  cfecum.  In  any  of  these  positions  the  appendix  may  be  more 
or  less  fixed  either  naturally  or  by  inflammatory  adhesions.  Occa- 
sionally the  appendix  has  no  mesenteric  fold,  but  is  applied  directly 
against  the  wall  of  the  csecum  and  covered  over  by  the  serous  layer 
that  invests  the  caecum.  Under  these  circumstances,  if  it  becomes 
necessary  to  remove  it,  the  peritoneal  layer  must  be  incised  and 
the  appendix  shelled  out  of  its  bed.  In  many  cases,  especially  if 
thickened,  the  appendix  can  be  palpated  through  the  abdominal  wall. 


462  ABDOMEN  AND  BACK. 

In  the  female  the  appendix  is  connected  with  the  broad  liga- 
ment by  a  thin  band,  the  so-called  appendieulo-ovarian  ligament 
and  is  frequently  found  adherent  to  the  right  uterine  appendages 
in  disease  of  these  organs.  The  appendix  is  frequently  diseased 
and  gives  rise  to  symptoms  of  its  own  in  connection  with  disease 
of  the  right  uterine  appendages: 

The  appendix  gets  its  arterial  supply  from  a  single  small  vessel 
derived  from  the  ileo-colic  which  is  a  branch  of  the  superior  mesen- 
teric. The  venous  return  is  through  a  corresponding  single  venous 
channel  which  empties  into  the  superior  mesenteric  vein.  These 
vessels  run  parallel  with  the  appendix  in  the  edge  of  the  mesentery 
between  its  two  layers;  when  the  mesentery  is  absent  they  are  found 
upon  the  surface  of  the  appendix,  beneath  its  serous  coat.  In  the 
female  the  appendix  receives  an  additional  vessel  through  the  appendi- 
culo-ovarian  ligament.  The  appendix  is  dependent  for  its  nutrition 
upon  this  very  limited  blood-supply  and  no  doubt  this  arrangement 
is,  at  least  in  part,  responsible  for  the  readiness  with  which  the  wall 
of  the  appendix  becomes  necrotic  when  its  circulation  is  disturbed. 

Occasionally  some  difficulty  may  be  experienced  in  finding  the 
appendix.  The  caecum  is  the  guide  to  the  appendix.  If  the  longi- 
tudinal bands  upon  the  caecum  are  traced  downward  they  will  be 
found  to  lead  directly  to  the  point  where  the  appendix  is  given  off  and 
therefore  these  bands  are  good  guides  to  the  root  of  the  appendix. 

Just  above  the  root  of  the  appendix  the  small  intestine  terminates 
by  entering  the  caecum;  it  enters  the  caecum  upon  its  left  side.  The 
opening  between  the  ileum  and  caecum  is  guarded  by  the  ileo-caecal 
valve.  This  valve  consists  of  two  folds  of  mucous  membrane  contain- 
ing some  circular  muscular  fibers.  These  folds,  projecting  into  the 
lumen  of  the  gut,  allow  the  contents  of  the  ileum  to  pass  freely  into 
the  caecum  but  prevent  the  reverse.  Fluids  injected  through  the 
rectum,  into  the  large  intestine,  cannot  pass  into  the  ileum  unless  this 
valve  is  forced  and  that  requires  enough  pressure  to  threaten  the 
rupture  of  the  large  intestine. 

The  AscENDiisrG  Colon. — This  is  the  continuation  upward  of 
the  caecum.  It  lies  close  to  the  posterior  wall  of  the  abdomen.  The 
ascending  colon  has  no  mesentery  and  is  only  partly  invested  by  the 
peritoneum,  it  being  absent  upon  its  posterior  surface.  The  ascending 
colon  ascends  along  the  outer  border  of  the  right  kidney,  lying  partly 
upon  the  kidney,  from  which  it  is  separated  by  some  interposed  loose 
connective  tissue  and  fat  only.  Continued  upward  as  far  as  the 
under  surface  of  the  liver  it  makes  a  turn — the  hepatic  flexure — and 


SURGICAL  ANATOMY  OF  THE  LARGE  INTESTINE.  463 

becomes  the  transverse  colon.  The  under  surface  of  tlie  liver  shows  a 
shallow  depression  corresponding  to  the  hepatic  flexure  and  here  the 
colon  is  attached  to  the  liver  l)y  a  reflection  of  peritoneum,  the  liga- 
mentuni  he])atico-colicum. 

The  Tkansverse  Colon  stretches  from  right  to  left  across  the 
upper  part  of  the  abdominal  cavity,  lying  below  the  first  part  of  the 
duodenum  and  greater  curvature  of  the  stomach.  Close  to  the  spleen, 
on  the  left  side,  the  colon  makes  a  second  turn, — the  splenic  flexure, — 
and  from  this  point  is  continued  downward  as  the  descending  colon. 
At  the  splenic  flexure  the  colon  is  fixed  to  tlie  diaphragm  by  a  fold 
of  peritoneum,  the  ligamentum  phrenico-colicum. 

The  transverse  colon  is  completely  invested  by  peritoneum  and 
has  a  long  mesentery  which  suspends  it  from  the  posterior  wall  of  the 
abdomen.  The  transverse  colon  enjoys  considerable  freedom  of  move- 
ment, but  is  connected  with  the  greater  curvature  of  the  stomach  by 
the  peritoneum. 

In  the  very  young  child  the  connection  of  the  transverse  colon 
to  the  greater  curvature  of  the  stomach  does  not  exist,  because  the 
layers  of  peritoneum  which  invest  the  stomach  and  unite  with  each 
other  at  the  greater  curvature  to  form  the  great  omentum  have  not 
become  adherent  to  the  peritoneum  which  envelops  the  transverse 
colon;   this  does  not  occur  until  later  in  life.     (See  Fig.  159.) 

The  Descexdixg  Colox  passes  downward  in  the  left  side  of 
the  abdominal  cavity,  lying  close  to  its  posterior  wall,  to  which  it  is 
partly  fixed.  It  has  no  mesentery,  is  only  partly  invested  by  the 
peritoneum,  and  cannot  be  drawn  out  upon  the  abdomen.  The  poste- 
rior wall  of  the  descending  colon,  which  is  devoid  of  peritoneum, 
lies  close  to  the  outer  border  of  the  left  kidney,  lying  partly  upon 
its  anterior  surface.     It  is  continued  below  into  the  sigmoid  flexure. 

The  Sigmoid  Flexure  is  the  last  part  of  the  colon;  it  is  a 
redundant  loop  of  gut  curved  upon  itself  and  lying  in  the  left  iliac 
fossa.  Its  caliber  is  rather  smaller  than  that  of  the  other  parts  of 
the  colon;  it  is  completely  invested  by  the  peritoneum  and  has  a 
fairly  long  mesentery  which  suspends  it  to  the  posterior  alxlominal  wall 
and  permits  much  freedom  of  motion.  The  layers  of  the  mesentery 
are  very  loosely  attached  to  each  other,  so  that  the  sigmoid  flexure  may 
readily  slip  down  between  them  and  escape  into  the  inguinal  canal, 
giving  rise  to  a  hernia  with  an  incomplete  sac.  ^Yhen  the  sac  is 
opened  it  will  be  found  that  the  sigmoid  is  attached  to  the  interior  of 
the  sac  and  cannot  be  detached,  because  the  mesenteric  folds  of  the 
sigmoid  are   directly  continuous  with  the   sac.     When  the  bowel  is 


464  ABDOMEN  AND  BACK. 

returned  into  tlie  abdomen  the  sac  must  be  returned  in  part  witli  it. 
In  most  cases  the  sigmoid  flexure  may  be  freely  drawn  out  upon  the 
abdominal  wall.  At  the  sacro-iliac  synchondrosis  it  is  continued  down 
into  the  pelvis  as  the  rectum. 

The  Blood-supply  of  the  Large  Intestine.  —  The  caecum, 
appendix,  and  ascending  and  transverse  colon  are  supplied  by  branches 
which  are  given  off  from  the  right,  or  concave,  side  of  the  superior 
mesenteric  artery. 

The  descending  colon  and  sigmoid  flexure  are  supplied  by  the 
inferior  mesenteric,  which  comes  off  from  the  front  of  the  aorta  just 
below  the  origin  of  the  superior  mesenteric ;  after  supplying  the  parts 
mentioned  this  vessel  dips  into  the  pelvis,  between  the  layers  of  the 
mesorectum,  to  supply  the  rectum  as  far  as  its  lower  end. 

The  arterial  branches  which  are  derived  from  the  superior  and 
inferior  mesenteric  for  the  supply  of  the  ascending  and  descending 
colon,  as  they  pass  to  their  destination,  lie  upon  the  posterior  abdominal 
wall  covered  by  the  j)eritoneum  which  lines  the  back  of  the  abdomen ; 
those  which  supply  the  caecum,  transverse  colon,  and  sigmoid  flexure, 
which  parts  of  the  large  intestine  are  provided  with  a  mesentery, 
reach  their  destination  between  the  layers  of  the  mesentery  correspond- 
ing to  the  part. 

The  veins  have  a  course  similar  to  the  corresponding  arteries. 
The  inferior  mesenteric  joins  with  the  splenic  vein,  which,  in  turn, 
unites  with  the  superior  mesenteric  to  form  the  portal;  hence,  blood 
from  the  intestinal  tract  and  rectum^  must  flrst  traverse  the  portal 
circulation  (through  the  liver)  before  entering  the  general  circulation. 
Poisonous  matter  may  be  absorbed  from  the  intestinal  tract  (colitis, 
hemorrhoids,  etc.)  and  cause  thrombosis  in  the  veins  leading  from 
these  parts  or  may  result  in  abscess  in  the  liver,  etc. 

As  is  the  case  with  the  vessels  of  the  small  intestine,  the  terminals 
of  the  arteries  that  are  distributed  to  the  large  intestine  do  not 
anastomose  freely  with  each  other;  hence  division  of  a  considerable 
branch  will  often  result  in  gangrene  of  the  corresponding  part  of  the 
gut. 

OPERATIONS    UPON    THE    LARGE    INTESTINE. 

Colostomy. — The  formation  of  a  fistulous  opening  into  the  large 
mtestine,  a  so-called  artificial  anus.  The  operation  is  resorted  to  in 
cases  of  obstruction  due  to  stricture  of  the  bowel,  and  as  an  emergency 


1  Some    venous    blood    from    the    rectum    enters    the    general    circulation    direct 
through  the  middle  and  inferior  hemorrhoidal  veins. 


OPERATIONS  UPON  THE  LARGE  INTESTINE.  4G5 

operation  for  the  purpose  of  saving  life  in  acute  intestinal  obstruction. 
The  operation  may  be  performed  as  a  temporary  measure  for  the  pur- 
pose of  draining  the  bowel  preliminary  to  undertaking  the  operation 
of  resection  of  the  rectum,  or  to  facilitate  the  healing  of  ulcerated 
areas  in  the  colon,  rectum,  etc.  It  is  desirable  in  all  cases  to  make  a 
complete  colostomy,  including  the  entire  calibre  of  the  gut  in  the 
artificial  anus.  In  this  way  a  spur  is  formed  between  the  two  openings 
which  result  from  the  operation,  double-barrel  shot-gun  fashion,  and 
in  this  manner  the  entrance  of  fecal  matter  into  the  lower  constricted 
or  diseased  portion  of  the  bowel  is  prevented. 

The  entrance  of  fecal  material  into  the  lower  part  of  the  bowel  is 
very  objectionable  and  is  to  be  avoided  if  possible.  It  accumulates 
and  l)ecomes  foul  in  cases  of  stricture,  and  in  those  cases  where  the 
colostomy  has  been  performed  as  a  preliminary  to  resection  of  the 
rectum  it  interferes  with  the  healing  process.  The  lateral  colostomy 
in  M'hich  no  spur  is  formed  should  be  done  in  those  cases  only  where, 
owing  to  short  mesentery,  adhesions,  etc.,  it  is  impossi1)le  to  draw 
a  loop  of  the  bowel  sufficiently  long  to  permit  of  the  spur  operation, 
out  of  the  abdominal  incision.  Even  in  these  cases  it  will  often  be 
possible  to  free  the  bowel  to  a  sufficient  degree  by  carefully  incising 
the  mesentery  or  breaking  up  adhesions. 

Left  Iliac  Colostomy. — Where  the  obstruction  is  in  the  rectum 
or  in  the  sigmoid,  the  artificial  anus  is  made  in  the  left  iliac  region. 
A  permanent  artificial  anus  is  established  in  the  left  iliac  region  in 
those  cases  where  the  rectum  has  been  extirpated  and  it  is  not  pos- 
sible to  draw  the  end  of  the  sigmaid  down  to  the  site  of  the  original 
anal  orifice ;  or  where  the  anal  sphincter  apparatus  has  been  sacrificed 
on  account  of  involvement  of  the  anal  portion.  The  incision  is  made 
parallel  with  Poupart's  ligament,  about  three  inches  long,  com- 
mencing above  about  one  inch  above  and  to  the  inner  side  of  the 
anterior  superior  spine  and  terminating  below  about  one  inch  al)ove 
the  middle  of  Poupart's  ligament.  The  incision  is  carried  through  the 
skin  and  fat  down  to  the  aponeurosis  of  the  external  oblique,  which  is 
split  in  a  line  corresponding  to  the  direction,  of  its  fibers.  The  fleshy 
portion  of  the  internal  oblique  muscle  is  thus  exposed.  The  fibers  of 
this  muscle  are  separated  with  the  handle  of  the  knife  in  the  direction 
of  their  course,  which  is  nearly  at  right  angles  to  the  line  of  the  skin 
incision.  The  fleshy  fibers  of  the  transversalis  are  next  exposed  and 
are  likewise  separated  bluntly.  Blunt  retractors  are  introduced  to  hold 
the  edges  of  the  incision  apart  and  the  transversalis  fascia  and  peri- 

30 


466  ABDOMEN  AXD  BACK. 

toneimi  are  incised  along  a  line  corresponding  to  the  direction  of 
the  skin  incision.  These  last  two  laj^ers  are  "usually  divided  as  one 
layer,  especially  in  thin  subjects.  The  edges  of  the  peritoneum 
and  transversalis  fascia  are  seized  with  two  artery  clamps,  one  on 
either  side  of  the  incision  and  taking  a  good  broad  bite.  The  fingers 
are  introduced  and  the  sigmoid  sought.  In  order  to  secure  this 
portion  of  the  bowel  two  fingers  are  introduced  into  the  abdomen 
and  carried  outward  and  backward,  gliding  upon  the  inner  surface 
of  the  abdominal  wall  as  far  as  the  lumbar  region,  where  the  colon 
is  found;  one  may  meet  with  coils  of  the  small  intestine  and  these 
may  get  in  the  way  of  the  fingers  but  they  may  be  recognized  on 
account  of  their  being  entirely  surroimded  by  peritoneum  and  are 
easily  pushed  aside ;  the  fingers  are  allowed  to  glide  from  the  poste- 
rior wall  of  the  abdomen  on  to  the  descending  colon  which  is  traced 
downward  until  its  continuation,  the  sigmoid  flexure,  is  reached. 
The  sigmoid  is  provided  with  a  long  mesentery  as  a  rule,  and  can 
be  drawn  freely  out  of  the  abdominal  incision.  The  loose  sigmoid 
flexure  is  not  used  to  form  the  artificial  anus.  On  account  of  its 
lengthy  mesentery  it  has  a  tendency  to  become  very  much  pro- 
lapsed and  this  is  undesirable.  The  sigmoid  flexure  is  drawn  out 
through  the  incision  working  ujoward  until  a  portion  of  the  bowel 
corresponding  to  the  lowest  part  of  the  descending  colon  is  secured. 
The  portion  of  the  bowel  selected  has  a  mesentery  which  is  just 
sufficiently  long  to  permit  of  a  loop  being  drawn  out  of  the  incision. 
The  rest  of  the  bowel  is  then  pushed  back  into  the  abdomen. 

Corresponding  to  the  middle-  of  the  incision  a  mattress  suture 
of  heavy  silk  is  passed  through  all  the  layers  of  both  edges  of  the 
incision,  passing  from  one  edge  of  the  incision  to  the  other  and 
transfixing  the  mesentery  in  its  course.  This  stitch  is  introduced 
with  a  large  full  curved  Hagedorn  needle.  It  is  introduced  about 
one  inch  awa}^  from  the  edge  of  the  incision,  penetrating  all  the 
layers  and  taking  care  to  see  that  it  takes  a  good  bite  in  the  peri- 
toneal layer.  It  passes  through  the  mesentery  of  the  loop  of  bowel 
about  one  inch  distant  from  the  bowel  and  without  wounding  any 
of  the  vessels.  The  needle  may  be  passed  through  the  mesentery 
blunt  end  first  and  selecting  a  point  free  from  blood-vessels.  The 
suture  then  passes  through  all  the  layers  of  the  opposite  edge  of 
the  incision.  It  is  passed  back  in  the  reverse  order  and  through 
the  same  hole  in  the  mesentery,  and  finally  through  the  first  edge 
of  the  incision  emerging  close  to  the  point  where  it  was  originally 
introduced.     This  stitch  is  the  suggestion  of  Ward.     It  does  not 


Fig.  217. — Colostomy.  A  loop  of  the  intestine  is  drawn  out  through  the 
incision.  A,  /),  sutures  that  penetrate  the  skin  and  fat  and  the  aponeurosis  of 
the  external  oblique  and  serve  to  close  the  upper  and  lower  ends  of  the  incision. 
B,  C.  sutures  that  go  through  the  peritoneum  and  transversalis  fascia  and  pick 
up  the  bowel  with  several  bites.  They  serve  to  close  the  incision  in  part  and  to 
secure  the  bowel  as  well.  M,  suture  that  penetrates  all  the  layers  of  the 
abdominal  wall  and  pierces  the  mesentery  of  the  loop  of  bowel.  It  serves  to 
bring  the   .  ili^cs   of   tin    incision   together  in  the   middle. 


Fig.  218. — Colostomy.  Sutures  all  tied.  Mesenteric  suture  is  tied  upon  a 
piece  of  rubber  tubing  on  each  side  of  the  incision  to  prevent  its  cutting  into 
the  skin. 


468  ABDOMEN  AND  BACK. 

serve  the  purpose  of  suspending  the  loop  of  gut.  but  when  drawn 
tight  and  tied  it  has  the  effect  of  bringing  the  two  edges  of  the 
incision  together  in  the  middle,  under  the  protruding  loop  of  bowel, 
practicall}'  dividing  the  incision  into  two  halves,  an  upper  for  the 
upper  arm  of  the  loop  of  gut  and  a  lower  for  the  lower  arm.  Before 
tying  the  mattress  suture,  additional  sutures  of  silk  are  introduced, 
two  in  the  upper  end  of  the  incision  and  two  in  the  lower  end. 
Of  these  sutures  the  uppermost  and  lowermost,  A  and  D,  penetrate 
the  skin  and  fat  and  the  aponeurosis  of  the  external  oblique  only. 
These  two  sutures  are  of  silk  and  serve  simply  to  close  the  incision  in 
part.  The  other  two  sutures,  B  and  C,  go  through  the  peritoneum 
and  transversalis  fascia  in  the  edges  of  the  incision,  and,  as  they  pass 
across  from  one  edge  of  the  incision  to  the  other,  they  pick  up  the 
wall  of  the  bowel  with  one  or  two  good  broad  bites,  but  without  pene- 
trating the  entire  thiclmess  of  the  wall  of  the  bowel.  These  sutures 
are  of  chromic  catgut  ISTo.  1  and  catch  the  wall  of  the  bowel  at  a  part 
corresponding  to  the  line  of  one  of  the  longitudinal  muscular  strise — 
in  this  way  insuring  a  very  secure  hold.  The  mattress  suture  is  drawn 
tight  and  tied  over  a  piece  of  rubber  tubing  in  the  loop  upon  either 
side  of  the  incision  in  order  to  prevent  the  suture  from  cutting  into 
the  skin.  The  mattress  suture  brings  the  edges  of  the  incision 
closely  together  in  the  middle  with  the  mesentery  of  the  sigmoid 
interposed  between  them,  and  obviates  any  danger  of  the  loop  of 
bowel  becoming  displaced  or  retracting  back  into  the  abdomen.  The 
sutures  A  and  B,  and  C  and  D  are  tied,  thus  closing  the  incision  in 
part  and  fixing  the  bowel  in  the  upper  and  lower  ends  of  the  incision. 

This  intramuscular  method  insures  a  fairly  continent  artificial 
anus.  As  the  split  muscles  return  to  their  natural  position  they 
grip  the  protruding  loop  of  bowel  pretty  tightly  and  thus  close  the 
artificial  anal  oj)ening. 

Fatty  appendices  hanging  from  the  loop  of  bowel  are  ligated 
and  cut  away. 

A  layer  of  rubber  tissue  is  placed  over  the  bowel  to  prevent  stick- 
ing of  the  dressings. 

The  loop  of  bowel  is  opened  by  longitudinal  incision  with  the 
knife  or,  better,  with  the  cautery  at  a  dull  red  heat  after  the  lapse 
of  several  days,  depending  upon  the  urgency  of  the  case.  When 
the  bowel  is  opened  it  will  be  seen  that  there  are  two  openings 
separated  by  a  partition  or  spur  that  prevents  the  entrance  of  mate- 
rial into  the  loAA-er  loop. 


OPERATIONS  UPON  THE  LARGE  INTESTINE.  469 


Fig.  219.— Colostomy.     Rubber  tube  fixed   in   the  loop  of  intestine 
with  a  purse-string  suture. 


470 


ABDOMEN  AND  BACK. 


If  necessary  to  open  the  bowel  immediately  this  may  be  done 
without  danger  of  soiling  by  inserting  a  thick  rubber  tube  or  a 
Paul  glass  tube  into  the  bowel.  The  loop  of  gut  is  emptied  by 
stripping  with  the  fingers  and  a  rubber-sheathed  holding  clamp 
applied  to  the  bowel  to  prevent  re-entrance  of  contents  until  the 
tube  has  been  secured  in  place.  A  purse-string  of  silk  is  introduced 
in  the  wall  of  the  bowel  and  a  small  incision  made.  A  small  amount 
of  intestinal  contents  that  escapes  is  caught  with  a  gauze  ^Yi'pe. 
The  rubber  tube  or  Paul's  tube  is  introduced  into  the  bowel  and 
secured    by    tying    the    purse-string    moderately    tight    around   it. 


Fig.  220. — Paul's  Tube.     Used  to  drain  the  colon  and  intestine. 


The  holding  clamps  are  removed.  The  tube  will  drain  the  bowel 
without  the  wound  becoming  soiled  until  adhesions  have  formed. 
If  the  rubber  tube  is  used  it  is  secured  from  becoming  displaced 
by  a  suture  that  fixes  it  near  the  edge  of  the  small  incision  in  the 
bowel. 

Eight  Iliac  Colostomy. — If  the  growth — obstruction — involves 
the  transverse  or  descending  colon,  the  operation  may  be  performed 
in  a  manner  similar  to  that  described  above  upon  the  right  side 
of  the  body;  in  this  case  the  lower  part  of  the  ascending  colon  is 
brought  out  through  the  incision  and  fixed. 

Lateeal  Colostomy  Without  a  Spur. — The  colostomy  with  a 
spur  just  described  is  preferable.  The  incision  is  similar  to  that 
described  in  the  preceding  paragraphs.     The  edge  of  the  peritoneum 


OPERATIONS  UPON  THE  LARGE  INTESTINE. 


471 


upon  each  side  is  fixed  to  the  corresponding  margin  of  the  skin, 
near  the  middle,  with  two  or  three  catgut  sutures;  this  is  done  to 
})revent  retraction  of  this  hiyer  of  peritoneum.  A  silk  stitch  (A, 
Fig.  221)  is  passed  through  the  edges  of  the  upper  part  of  the 
incision,  through  all  the  layers,  including  the  skin  and  the  edges 
of  the  peritoneum;  a  second  similar  suture  (D,  Fig.  221)  is  passed 
through  the  lower  ]}art  of  the  incision.  Tliese  two  sutures  are  not 
tied  until  later.     The  lower  part  of  the  descending  colon  is  sought 


Fig.  221.— Colostomy.  The  waU  of  the  descending  colon  drawn  into  the 
incision  and  fixed.  A,  D,  stitches  which  pass  through  all  the  layers  of  the 
abdominal  wall,  including  the  peritoneum;  B,  C,  stitches  which  pass  through 
all  the  layers  of  the  abdominal  wall,  including  the  peritoneum,  but  catch  up 
the  wall  of  the  gut  as  well  in  their  course. 


for  and  drawn  into  the  incision,  and  while  the  gut  which  has  been 
selected  is  steadied  in  the  wound  a  silk  stitch  {B,  Fig.  221)  in  a 
curved  surgeon's  needle  is  passed  through  the  upper  part  of  one 
edge  of  the  incision,  through  all  the  layers,  care  being  taken  to 
include  the  peritoneum ;  it  then  passes  superficially  through  the 
wall  of  the  gut,  picking  up  its  serous  and  muscular  coats  and  taking 
a  good,  broad  bite  or  several  bites,  along  the  line  of  the  longitudinal 
muscular  striae,  but  not  penetrating  into  its  lumen,  and  finally  is 
brought  out   through  the  opposite   edge  of  the   abdominal   incision. 


472  ABDOMEN  AND  BACK. 

A  second  stitch  {C,  Fig,  321)   is  similarly  introduced  in  the  lower 
part  of  the  abdominal  wound,  and  this  also  catches  the  wall  of  the 


Fig.  222. — Colostomy.  Shows  the  result  of  complete  colostomy  with  spur. 
Two  openings  result  with  a  spur  or  partition  between  them  that  prevents  the 
contents  from  the  upper  segment  of  gut  from  passing  into  the  lower  segment. 


Fig.  223. — Colostomy.  Shows  the  result  of  lateral  colostomy.  No  spur  is 
formed  and  contents  from  the  upper  segment  may  pass  readily  into  the  lower 
segment. 

bowel  on  the  way.  These  two  stitches  (B  and  0)  should  be  about 
two  inches  apart  and  may  now  be  tied,  likewise  the  two  stitches 
previously  introduced  through  the   edges  of  the  wound,   above   and 


OPERATIONS  UPON  THE  LARGE  INTESTINE.  473 

below,  and  the  bowel  is  thus  partially  fixed  in  the  abdominal  inci- 
sion. The  bowel  is  still  further  fixed  to  the  margins  of  the  abdomi- 
'nal  incision  by  three  or  four  interrupted  fine  chromic  catgut  sutures 
on  either  side;  each  one  of  these  secures  the  serous  and  muscular 
coats  of  the  bowel  and  the  edge  of  the  incision  in  the  abdomen, 
including  the  parietal  peritoneum  and  skin.  They  may  be  intro- 
duced with  a  small,  curved  surgeon's  needle. 

If  the  condition  is  not  very  urgent  the  bowel  had  better  not  be 
opened  until  after  the  lapse  of  from  twenty-four  to  forty-eight  hours, 
or  even  longer,  thus  allowing  time  for  adhesions  to  form  and  shut  off 
the  peritoneal  cavity. 

Resection  of  the  Caecum. — This  may  include,  in  addition  to  the 
caecum,  the  whole  or  a  part  of  the  ascending  colon  and  part  of  the 
ileum.     For  malignant  disease,  tuberculosis,  and  intussusception. 

If,  before  operating,  the  disease  can  be  located  in  this  part  of  the 
gut  or  a  tumor  felt,  the  incision  is  probably  best  placed  directly  over  the 
tumor  penetrating  through  the  outer  part  of  the  right  rectus  muscle. 
If  the  incision  is  made  primarily  for  the  purpose  of  exploration,  the 
location  of  the  tumor  not  having  been  previously  ascertained,  then 
it  is  usually  placed  in  the  middle  line,  reaching  from  the  umbilicus 
downward,  toward  the  symphysis;  through  this  incision  the  caecum 
may  also  be  excised  if  found  advisable.  In  either  case  the  incision 
must  be  long  enough  to  allow  sufficient  room  for  work. 

If  the  incision  is  made  through  the  outer  part  of  the  rectus  it 
commences  about  one  inch  above  the  middle  of  Poupart's  ligament  and 
is  carried  in  a  direction  upward  to  a  point  located  midway  between  the 
umbilicus  and  the  anterior  superior  iliac  spine  or,  if  necessary,  it  may 
be  continued  farther  upward  toward  the  tip  of  the  tenth  rib.  It  may 
vary  from  five  to  ten  inches  in  length.  We  may  find  it  necessary  to 
separate  some  adhesions  before  the  cscum  is  exposed.  This  portion 
of  the  bowel  together  with  the  adjoining  part  of  the  ileum,  is 
brought  out  of  the  incision  upon  the  abdomen. 

The  cfficum  being  steadied  outside  the  abdominal  incision,  is 
surrounded  by  gauze  pads  to  protect  the  abdominal  cavity  and  two 
strips  of  narrow  tape  are  tied  about  the  bowel  beyond  the  part  which 
is  to  be  excised.  Before  tying  the  second  piece  of  tape  the  segment 
of  gut  should  be  emptied  by  stripping  it  between  the  fingers. 

The  mesentery  corresponding  to  the  segment  of  gut  which  is  to  be 
excised  is  tied  off  in  sections  with  catgut  ligatures.  The  ligatures  may 
be  carried  in  the  eye  of  a  blunt  ligature  carrier  or  with  a  pointed-nosed 
artery  forceps.     Each  ligature  should  be  single  and  placed  some  dis- 


474  ABDOMEN  AND  BACK. 

tance  away  from  the  gut  so  as  to  leave  space  to  cut  between  them  and 
the  gut.  The  segment  of  gut  which  is  to  be  excised  is  detached  by 
cutting  its  mesentery  between  the  ligatures  and  the  gut.  One  should 
take  care  to  excise  all  of  the  gut  whose  mesentery  has  been  tied  off, 
because,  if  an  end  of  the  gut  which  has  been  deprived  of  its  mesentery, 
and  hence  its  blood-supply,  is  left,  it  is  slow  to  unite  and  may  become 
gangrenous.  It  remains  to  divide  the  gut  above  and  below,  thus 
removing  the  diseased  segment.  This  is  done  with  a  long,  straight 
scissors  in  one  sweep,  long  clamps  having  been  previously  placed  upon 
the  gut  to  close  the  diseased  segment  in  order  to  prevent  the  escape 
of  its  contents  when  it  is  cut. 

Instead  of  proceeding  as  above,  one  may,  after  the  tapes  and 
compression  clamps  have  been  applied  to  the  gut,  divide  the  gut  above 
and  below  the  diseased  area  and  then  tie  off  the  corresponding  part  of 
the  mesentery  in  sections  as  described. 

We  are  then  ready  for  the  final  step  of  the  operation,  the  restora- ' 
tion  of  the  continuity  of  the  alimentary  canal  by  joining  the  ileum  to 
the  colon  (ileo-colostomy),  and  this  may  be  accomplished  by: — 

1.  End-to-end  anastomosis. 

2.  Lateral  anastomosis  with  suture,  clamps  or  McGraw's  rubber 
ligature. 

3.  Lateral  implantation  with  suture  or  Murphy  button. 
End-to-End  Anastomosis. — This  method  may  be  employed  if 

both  ends  of  the  gut  which  are  to  be  united  are  of  the  same  caliber. 
This  condition  at  times  exists,  owing  to  the  fact  that  the  obstruction 
in  the  csecum  or  at  the  ileo-csecal  opening  may  have  caused  a  dilata- 
tion and  hypertrophy  of  the  ileum,  the  large  intestine  at  the  same 
time  having  become  more  or  less  diminished  in  caliber. 

The  anastomosis  may  be  made  with  suture  in  a  manner  similar  to 
that  described  in  end-to-end  anastomosis  of  the  small  intestine.  If 
the  two  ends  of  gut  are  of  unequal  lumen  the  larger  must  be  reduced 
hy  infolding  a  portion  so  that  it  will  correspond  in  size  with  the 
smaller  (see  "End-to-end  Anastomosis,  Small  Intestine"). 

Lateral  Anastomosis.  —  This  is  a  satisfactory  method  of 
restoring  the  continuity  of  the  intestinal  canal,  particularly  if  the 
ends  are  of  unequal  size;  for  example,  in  joining  the  ileum  to  the 
caecum  or  colon  (see  "Lateral  Anastomosis,  Small  Intestine"). 

The  cut  edge  of  each  segment  of  gut  is  inverted,  a  margin  of  from 
three-fourths  to  one  inch  being  turned  in  and  the  opening  closed  with 
a  continuous  suture  of  chromic  catgut  which  passes  through  the  serous 
and  muscular  coats,  always  taking  special  care,  particularly  at  the 


OPERATIONS  UPON  THE  LARGE  INTESTINE.  475 

mesenteric  border,  to  appose  serous  surfaces  to  each  otlier.  A  second 
continuous  silk  suture  is  then  introduced;  this  second  suture  also 
includes  only  the  serous  and  muscular  coats  and  serves  to  bury  the 
first  line  of  suture.  After  the  ends  of  the  bowel  have  been  thus 
closed  up  they  are  placed  side  to  side  overlapping  each  other  for  a 
distance  of  about  five  inches  and  they  are  then  united,  surface  to 
surface,  for  a  distance  of  three  or  four  inches  with  a  continuous 
Lembert  suture  of  fine  silk.  This  line  of  suture  forms  the  first  half 
of  the  "outside  serous  ring,"  suture  and  when  it  has  been  introduced 
the  needle  with  the  thread  left  long  is  temporarily  laid  aside.  An 
incision  is  made  in  each  segment  of  the  gut  about  three  inches  long  but 
not  so  long  as  the  line  of  the  Lembert  suture  (one  inch  shorter)  and  at 
a  distance  of  about  one-fourth  inch  away  from  the  line  of  the  Lembert 
suture.  The  corresponding  edges  of  these  incisions  are  sewed  together 
all  around  with  a  continuous  overhand  suture  of  chromic  catgut  which 
includes  all  the  coats  of  the  gut.  After  the  edges  of  the  openings  have 
been  thus  united,  the  needle  with  which  the  first  half  of  the  "outside 
serous  ring"  suture  was  made  is  again  taken  up  and  the  second  half 
of  the  "outside  serous  ring,"  Lembert  suture,  inserted.  The  gut  is 
kept  free  of  contents  during  the  operation,  as  usual,  by  constricting  it 
with  strips  of  narrow  tape  passed  around  each  segment  of  gut  beyond 
the  site  of  the  operation. 

After  the  segments  of  the  gut  have  been  joined  together  and  the 
anastomosis  formed,  the  parts  are  wiped  clean  with  a  gauze  pad  wet 
with  hot  saline,  any  rent  or  opening  remaining  in  the  mesentery  closed 
with  several  sutures  of  plain  catgut  and  the  parts  returned  to  the 
alxlomen. 

The  lateral  anastomosis  may  also  be  made  with  the  clamps, 
McGraw  rubber  ligature.  Murphy  button.  The  technique  of  these 
methods  has  been  described  elsewhere  in  the  volume. 

End-to-Side,  Lateral  Implantation. — The  technique  of  this 
operation  is  analogous  to  that  employed  in  Kocher's  method  of  implan- 
tation of  the  end  of  the  duodenum  in  the  stump  of  the  stomach  (see 
"Pylorectomy").  The  operation  may  be  done  with  the  suture  or  with 
tlie  Murphy  button.  After  the  end  of  the  large  intestine  has  been 
inverted  and  closed  by  suture  the  end  of  the  ileum  is  united  to  the 
edges  of  an  opening  which  is  made  in  the  wall  of  the  large  intestine 
opposite  its  mesenteric  border,  corresponding  to  one  of  the  longitudinal 
strias. 

Ileo-colostomy  Without  Resection  of  the  Caecum  or  Colon. — This 
operation  may  be  done  in  cases  of  obstruction  at  the  ileo-cfecal  valve 


476  ABDOMEN  AND  BACK. 

when  the  advisability  of  a  more  radical  operation — resection — is  doubt- 
ful. A  lateral  anastomosis  may  thus  be  made  between  the  ileum  and 
the  ascending  coion^  or,  if  the  obstruction  is  located  in  another  part  of 
the  colon,  the  anastomosis  may  be  made  between  the  ileum  and  the 
sigmoid  flexure.  Care  should  be  taken  to  secure  a  coil  of  small 
intestine  as  low  down,  near  the  caecum,  as  possible;  so  that  the 
nutrition  of  the  patient  may  not  be  seriously  interfered  with.  The 
details  of  the  operation  are  similar  to  those  described  in  the  preceding 
paragraphs  (see  "Lateral  Anastomosis"). 

Resection  of  the  Sigmoid  Flexure. — This  operation  is  usually 
performed  for  malignant  obstruction.  This  part  of  the  large  intestine 
is  a  favorite  seat  of  malignant  disease. 

The  incision  is  probably  best  made  analogous  to  that  for  excision 
of  the  caecum  but  upon  the  other  side  of  the  abdomen,  through  the 
outer  part  of  the  left  rectus,  commencing  below,  about  one  inch  above 
the  middle  of  Poupart's  ligament.  The  sigmoid  may  also  be  resected 
through  an  incision  in  the  linea  alba,  extending  from  the  umbilicus 
downward  to  the  symphysis  pubis  if  such  an  incision  has  already  been 
made  for  the  purpose  of  exploration  before  the  growth  was  definitely 
located. 

The  sigmoid,  owing  to  its  long  mesentery,  may  be  readily  drawn 
out  through  the  abdominal  incision.  It  is  surrounded  by  gauze  pads 
to  protect  the  abdominal  cavity  and.  after  the  mesentery  which  is 
usually  quite  long,  has  been  tied  off  in  sections,  that  part  of  the  bowel 
which  is  to  be  resected  is  clamped  off,  cut  free  from  its  mesenteric 
attachment,  and  finally  excised.  The  ends  of  the  bowel  are  then 
united,  end  to  end,  by  suture  or  with  a  large  Murphy  button,  as 
described  in  resection  of  the  cascum,  etc. 

If  the  sigmoid  is  fixed  and  the  neighboring  parts  already 
infiltrated,  it  may  be  better  to  make  an  artificial  anus  above  the  seat  of 
obstruction  and  omit  the  radical  operation. 

Malignant  disease  is  frequently  encountered  at  the  hepatic  flexure 
of  the  colon,  rather  less  commonly  at  the  splenic  flexure.  When  the 
disease  is  located  at  the  hepatic  flexure  the  gall-bladder  and  liver  are 
usually  already  hopelessly  involved  in  the  disease. 

The  colon  may  be  resected  at  the  hepatic  and  the  splenic 
flexures,  the  incision  being  made  above,  through  the  outer  part  of  the 
corresponding  rectus,  or  in  the  middle  line,  from  the  ensiform  cartilage 
downward  to  or  beyond  the  umbilicus.  The  continuity  of  the  canal 
may  be  restored  by  any  one  of  the  methods  described  above,  preferably 
the  end-to-end  with  the  suture. 


OPERATIONS  UPON  THE  VERMIFORil  APPENDIX.  477 

OPERATIONS    UPON   THE   VERMIFORM    APPENDIX. 

Appendicectomy. — Eenioval  of  the  appendix. 

As  performed  in  cases  of  chronic  rehipsing  catarrhal  and  recur- 
rent appendicitis  and  in  acute  cases  that  have  not  yet  gone  on  to 
suppuration — in  all  cases  that  are  not  complicated  by  abscess  forma- 
tion and  that  do  not  require  drainage.  In  these  cases  the  McBurney 
gridiron  or  the  mid-rectus  incision  is  used,  and  the  incision  is  closed 
up  immediately  without  drainage. 

The  McBurney  Gridiron"  Incision. — ^This  method  obviates  the 
likelihood  of  subsequent  hernia  and  should  be  employed  whenever 
possible.  The  skin  is  incised  in  an  oblique  direction  from  above, 
downward  and  inward.  The  incision  is  about  three  inches  long. 
This  incision  may  be  lengthened  later  if  it  becomes  necessary.  In 
fat  subjects  it  is  well  to  make  a  liberal  incision  through  the  integu- 
ment and  fat.  In  penetrating  through  the  aponeurosis  and  muscle, 
etc.,  the  incision  may  be  made  as  short  as  is  compatible  with  the 
proper  performance  of  the  operation.  The  incision  should  be  placed 
about  one  and  one-half  inches  to  the  inner  side  of  the  anterior 
superior  iliac  spine,  crossing,  almost  at  a  right  angle,  a  line  drawn 
from  the  anterior  superior  spine  to  the  umbilicus  and  so  arranged 
that  one-third  of  the  length  of  the  incision  is  above  the  line  and 
two-thirds  below  it.  The  aponeurosis  of  the  external  oblique  is 
exposed  and  split  by  separating  between  its  fibers,  and  then  two 
broad,  sharp  retractors  are  introduced,  and,  retracting  the  skin  and 
aponeurosis,  the  muscular  fibers  of  the  internal  oblique  are  exposed; 
these  are  not  cut,  but  are  separated  with  the  handle  of  the  knife 
in  the  direction  of  the  fibers,  which  is  nearly  at  a  right  angle  to 
the  direction  of  the  skin  incision.  The  fibers  of  the  transversalis 
muscle  are  next  exposed  and  separated  in  a  similar  manner.  With 
two  blunt  retractors  the  edges  of  the  muscles  are  drawn  apart  and 
the  transversalis  fascia  exposed.  This  layer  is  incised  and  finally  the 
peritoneum.  These  last  two  layers  are  divided  in  the  same  direction 
as  the  internal  oblique ;  i.  e.,  at  right  angles  to  skin  incision.  They 
are  picked  up  with  two  mouse-toothed  forceps  and  divided  between 
these  in  order  to  avoid  injuring  the  underlying  gut  which  may  lie 
close  to  the  peritoneum  or  be  adherent  to  it.  The  fascia  and  the 
peritoneum  may  be  divided,  each  separately.  Occasionally  they  lie  in 
such  intimate  relation,  one  to  the  other,  that  they  are  divided  as 
one  layer. 


478  ABDOMEN  AND  BACK. 

The  incision  is  closed  by  snturing  the  edges  of  the  peritoneum 
and  transversalis  fascia  together  with  a  continuous  stitch  of  plain 
catgut.  The  edges  of  the  transversalis  fascia  are  picked  up  and 
included  with  the  peritoneum  in  order  to  give  more  security  to  this 
layer  of  suture.  The  edges  of  the  muscles  of  themselves  return  to 
place  and  are  secured  by  two  or  three  interrupted  catgut  sutures. 
The  aponeurosis  of  the  external  oblique  is  sewed  with  a  continuous 
catgut  suture  from  above  downward  and  the  skin  closed  with  an 
intracuticular   catgut   suture. 

The  Mid-rbotus  Incision. — This  is  a  most  satisfactory  in- 
cision. It  is  of  especial  value  in  those  cases  where  there  is  doubt 
as  to  the  presence  of  pus.  It  permits  easy  access  to  the  appendix 
in  simple  catarrhal  cases  and  likewise  is  adapted  to  those  cases 
complicated  with  abscess  and  where  drainage  will  be  necessary. 
With  proper  closure  there  is  no  likelihood  of  subsequent  hernia. 
The  tubes  and  ovaries  may  also  be  reached  through  this  incision 
and  they  are  frequently  found  diseased  when  the  abdomen  has  been 
opened  for  appendicitis. 

A  vertical  incision  about  four  inches  long  is  made  over  the 
middle  of  the  right  rectus  muscle.  This  incision  penetrates  through 
the  skin  and  fat  down  to  the  aponeurosis  of  the  external  oblique. 
The  lower  two-thirds  of  this  incision  should  be  below  a  line  which  is 
drawn  from  the  anterior  superior  spine  to  the  umbilicus.  The 
aponeurosis,  which  really  forms  the  anterior  layer  of  the  sheath  of 
the  rectus,  is  divided  with  the  scissors.  The  operator  penetrates 
between  the  fleshy  fibers  of  the  rectus  bluntly  with  the  fingers  or  the 
end  of  the  blunt  scissors.  The  deep  epigastric  artery  and  vein  are 
seen  passing  across  the  bottom  of  the  incision  beneath  the  fascia  trans- 
versalis.    They  must  be  draAvn  to  one  side  or  clamped  and  ligated. 

In  closing  the  incision,  the  several  layers  must  be  sutured  sepa- 
rately— first,  the  peritoneum,  and,  included  with  this  layer,  the  fascia 
transversalis  and  posterior  layer  of  the  rectus  sheath  with  plain  catgut. 
The  edges  of  the  rectus  muscle  are  approximated  with  several  inter- 
rupted sutures  of  plain  catgut.  The  edges  of  the  aponeurosis  of 
the  external  oblique  (anterior  Isijer  of  the  sheath  of  the  rectus)  are 
united  with  a  continuous  suture  of  chromic  catgut,  No.  2,  and, 
finally,  the  edges  of  the  skin  are  united  with  an  intracuticular  suture 
of  plain  catgut. 

After  the  abdomen  has  been  opened  by  either  of  the  methods 
described  above,  we  may  proceed  with  the  next  step  of  the  opera- 


f 

OPERATIONS  I'PON  THE  VERMIFORM  APPENDIX.  479 

tion.  tlie  scare])  for  the  appendix.  At  times  it  may  he  found  pre- 
senting at  once  in  the  wound,  more  or  less  changed,  thickened,  etc., 
or,  occasionally  heing  hound  down  and  fixed  within  the  ahdomen  by 
adhesions,  it  does  not  come  into  view  and  tlien  it  will  he  necsesary 
to  search  for  it. 

The  apendix  may  hv  directed  downward  and  may  dip  into 
tlie  pelvis,  oi',  with  its  liip  pointed  upwai'd,  it  may  lie  to  the  outer 
or  to  the  inner  side  of  the  ca-cnm.  It  may  be  more  or  less  confined 
in  any  of  these  positions  l)y  its  mesentery  or  by  adhesions.  If  dif- 
ficulty is  experienced  in  finding  the  appendix,  the  ca?cum  may  be 
brought  out  of  the  incision  to  serve  as  a  guide.     The  caecum  is  the 


Fig.  224.— Appendicectomy.     Ligature  passed   around   the   meso- 
appendix  ready  to  tie. 

guide  to  the  appendix  and  is  identified  by  its  sacculation,  by  the 
little  fatty  processes  attached  to  it  and  by  its .  longitudinal,  white 
striffi,  two  of  which  can  usually  be  seen:  if  these  striaj  are  followed 
they  will  be  found  to  lead  down  to  the  point  where  the  appendix  is 
given  off.  Occasionally  the  appendix  is  applied  directly  against  the 
wall  of  the  caecum,  covered  over  Ijy  the  serous  layer  that  invests  the 
ca?cum.  In  order  to  remove  it,  it  would  be  necessary  to  incise  the 
peritoneal  layer  that  covers  it  and  peel  it  out  of  its  bed. 

The  appendix  is  gently  liberated  from  its  adhesions  with  the 
fingers, — there  is  no  danger  of  hemorrhage  in  this  procedure, — and 
gradually  it  is  brought  out  of  the  incision,  the  Cc^cum  being  at  the 
same  time  returned  into  the  abdomen.  Care  should  be  exercised 
to  detach  the  appendix  all  the  way  back  as  far  as  its  root. 


480 


ABDOMEJSr  AND  BACK. 


After  the  appendix  has  been  sufficiently  freed  it  is  drawn  out 
through  the  incision  and  its  mesentery  is  tied  off.  This  is  done 
by  transfixing  the  mesentery  close  to  the  appendix  and  near  its 
root  with  a  ligature  carrier  or  with  a  needle  carrying  a  piece  of 
Ko.  2  plain  catgut.  This  ligature  is  tied  and  the  appendix  then 
cut  away  from  the  mesenter}^^  cutting  between  the  appendix  and 
the  ligature  with  the  scissors.  If  the  mesentery  is  unusually  broad 
several  ligatures  may  be  used,  taking  the  mesentery  in  several  bites. 
The  appendix  having  been  thus  cut  away  from  its  mesentery  all 
the  way  back  to  its  root,  we  are  ready  to  proceed  with  the  final 


~BO 


Fig.  225.— Appendicectomy.  Mesoappendix  has  been  llgated.  Ligature  tied 
around  root  of  appendix  and  the  organ  amputated.  The  stump  has  not  been 
inverted. 


step   of   the  operation, — the    removal    of    the    appendix.      This    may 
be  done  in  one  of  several  ways. 

1.  Ligature  Without  Inversion.- — After  the  mesentery  has 
been  tied  oft'  and  cut  away  from  the  appendix  with  the  scissors,'  a 
catgut  ligature  (No.  2)  is  tied  securely  around  the  appendix  about 
one-fourth  inch  distant  from  its  root;  the  ends  of  this  ligature  are 
left  long  to  serve  as  a  temporary  tractor.  The  appendix  is  seized 
with  an  artery  clamp  upon  the  distal  side  of  the  ligature  to  prevent 
leakage  when  it  is  cut,  and  with  a  straight  scissors  it  is  amputated 
between  the  clamp  and  ligature.  While  the  stump  of  the  appendix 
is  steadied  by  making  traction  with  the  ligature  which  was  left 
long  intentionally  for  that  purpose,  the   raw  end  of  the   stump   is 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX. 


481 


touched  with  pure  carbolic  acid  on  a  small  probe  or  else  it  is  cau- 
terized with  a  pointed  Paquelin.  The  ligature  is  cut  short  and  the 
stump  of  the  appendix  allowed  to  drop  back  into  the  abdomen. 
This  is  a  safe  way  of  dealing  with  the  appendix  stump  and  is  espe- 
cially satisfactory  in  cases  where  unusual  difficulty  would  be  experi- 
enced in  inverting  it,  etc. 

2.  Inversion  of  the  Stump  or  the  Appendix  with  Purse- 
string  (Dawbarn). — After  the  mesentery  has  been  ligated  and  cut 
free   from   the   appendix,   the   latter  is   steadied   and   a   purse-string 


Fig.  226. — Appendicectomy.  Mesoappendix  has  been  ligated  and  a  purse- 
string  suture  has  been  introduced  around  the  root  of  the  appendix,  and  the 
organ  amputated.  The  stump  is  seized  with  a  forceps  preliminary  to  invert- 
ing it  into  the  c£ecum. 


suture  of  No.  1  chromic  catgut  introduced  in  the  wall  of  the  caecum 
so  as  to  surround  the  root  of  the  appendix  at  a  distance  of  about 
one-fourth  inch  all  around.  This  suture  should  include  only  the 
serous  and  muscular  coats  of  the  c<ficum ;  yet,  even  at  the  risk  of 
penetrating  into  the  lumen  of  the  bowel,  it  should  take  a  good, 
secure  bite  with  each  stitch.  The  purse-string  suture  is  not  drawn 
tight  nor  tied,  but  the  first  loop  of  a  surgeon's  knot  is  taken.  Then, 
without  applying  any  ligature  around  its  root  the  appendix  is  seized 
with  an  artery  forceps  and  cut  away  with  the  scissors,  leaving  a 
stump  about  one-quarter  inch  long.  The  stump  does  not  bleed. 
The  cut  end  of  the  stump  is  seized  with  a  thumb  forceps  without 

31 


482  ABDOMEN  AND  BACK. 

teeth  and  inverted  into  the  caecum;  it  is  turned  "outside  in"  like 
a  reversed  glove  finger.  The  forceps  is  withdrawn  and  at  the  same 
time  the  purse-string  is  drawn  tight,  thus  leaving  the  inverted 
stump  presenting  into  the  caecum  and  closing  the  opening  in  the 
caecum.  Occasionally  there  is  some  difficulty  in  inverting  the  stump 
on  account  of  the  narrowness  of  the  lumen.  This  is  overcome  by 
dilating  the  lumen  by  using  a  narrow-bladed  artery  forceps  like  a 
glove-stretcher. 

This  is  a  very  convenient  and  safe  method  of  disposing  of  the 
stump  of  the  appendix. 

3.  Inversion  of  the  Appendix  (Edebohls). — This  procedure 
is  applicable  to  cases  of  catarrhal  appendicitis  that  do  not  demand 
amputation  of  the  organ.  It  may  also  be  practiced  incidentally 
during  the  course  of  other  abdominal  operations  in  order  to  preclude 
the  possibility  of  the  appendix  becoming  a  source  of  trouble  at  some 
future  time.  The  meso-appendix  is  first  tied  off  close  to  the  root 
of  the  appendix  and  then  cut"  away  from  the  appendix  for  its  whole 
length.  The  point  of  a  probe  is  applied  to  the  tip  of  the  appendix, 
and  with  this  the  appendix  is  turned  "outside  in"  into  the  lumen 
of  the  caecum  as  one  would  reverse  the  finger  of  a  glove.  After 
the  appendix  has  been  inverted  into  the  caecum  and  while  it  is  thus 
held  with  the  probe  by  which  it  was  inverted  one  or  two  stitches 
of  chromic  catgut  are  taken  so  as  to  close  the  orifice  that  corre- 
sponds to  the  root  of  the  turned-in  appendix.  The  probe  is  then 
withdrawn  and  if  necessary  another  stitch  may  be  taken.  After 
the  mesentery  has  been  ligated  it  should  be  trimmed  away  very 
close  to  the  appendix  in  order  to  diminish  the  bulk  of  the  organ 
and  facilitate  the  process  of  inverting  it  into  the  caecum.  The 
stitches  that  unite  the  margins  of  the  orifice  that  corresponds  to 
the  root  of  the  turned-in  appendix  serve  to  retain  the  appendix 
in  its  new  inverted  condition;  they  are  of  chromic  catgut  and,  of 
course,  are  non-penetrating. 

After  the  appendix  has  been  amputated,  stump  turned  in,  etc., 
the  cfficum  is  mopped  off  with  a  gauze  wipe  wet  in  hot  saline  and 
returned  to  the  abdomen.  The  incision  in  the  abdomen  is  closed 
as  indicated  above  without  drainage. 

Operation  for  Appendicular  Abscess. — Cases  that  go  on  to  sup- 
puration, resulting  in  the  formation  of  a  localized  intraperitoneal 
abscess  which  is  shut  off  from  the  general  peritoneal  cavity  by 
adhesions  between  immediately  adjacent  peritoneal  surfaces.  The 
abscess  should  be  opened  and  drained  and  the  appendix  removed. 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.  483 

•  The  incision  in  cases  where  an  abscess  has  been  previously  diag- 
nosticated is  made  over  the  middle  of  the  right  rectus  muscle.  This 
incision  is  three  or  four  inches  long  and  may  be  increased  if  neces- 
sary to  allow  a  proper  exposure,  etc.  The  incision  crosses  the  line 
drawn  from  the  anterior  superior  iliac  spine  to  the  umbilicus,  one- 
third  of  the  incision  above  the  line  and  two  thirds  below  the  line. 
The  incision  is  carried  through  the  abdominal  wall  layer  by  layer. 
The  cut  through  the  skin  and  fat  exposes  the  aponeurosis  of  the 
external  oblique  (anterior  layer  of  the  sheath  of  the  rectus).  This 
layer  is  incised  and  split  for  the  full  length  of  the  incision  with  the 
scissors.  The  operator  penetrates  bluntly  with  the  fingers  or  blunt- 
pointed  scissors  between  the  fibers  of  the  rectus  muscle.  The  deep 
epigastric  artery  and  vein  are  seen  in  the  bottom  of  the  incision,; 
they  are  clamped  double,  cut  between  and  ligated.  The  transver- 
salis  fascia  (posterior  layer  of  the  sheath  of  the  rectus)  and  the 
peritoneum  are  next  incised.  They  are  picked  up  with  two  mouse- 
toothed  forceps  and  incised  between  these.  In  some  cases,  especially 
in  thin  people  with  little  or  no  subperitoneal  fat,  these  two  layers 
are  incised  as  one;  In  fat  people  they  will  usually  be  incised  as  two 
separate  layers.  Care  is  exercised,  in  incising  the  peritoneal  layer, 
not  to  injure  the  underlying  bowel.  The  gut  may  be  adherent  to  the 
peritoneum  or  may  float  up  against  the  peritoneum  so  as  to  lie 
directly  underneath  it.  In  some  cases  the  incision  may  be  placed 
somewhat  differently  from  that  just  described  in  order  to  better 
expose  the  inflammatory  tumor  mass;  it  may  be  placed  rather  nearer 
the  outer  border  of  the  rectus  muscle  or  lower  down,  rather  nearer 
Poupart's  ligament. 

The  location  of  the  abscess  varies  in  different  cases.  In  some  it 
is  located  anterior  to  the  cascum  within  a  mass  of  matted  guts  and, 
under  these  circumstances,  may  be  opened  as  soon  as  the  incision  is 
carried  through  the  peritoneal  layer.  In  other  cases  the  abscess  is 
situated  behind  the  Ciecum,  reaching  upward  toward  the  kidney  and 
liver.  In  still  other  cases  the  abscess  is  found  to  the  outer  or  to  the 
inner  side  of  the  cgecum,  reaching  upward  toward  tlie  liver  or  down- 
ward into  the  pelvic  cavity.  In  some  cases  the  abscess  lies  almost 
entirely  within  the  pelvic  cavity  and  causes  symptoms  due  to  pressure 
on  the  bladder  and  rectum  and  may  be  detected  through  the  vagina. 
Occasionally  there  is  more  tlian  one  collection,  and  care  should  be 
exercised  that  such  a  condition  does  not  escape  our  attention  at  the 
time  of  operation. 


484  ABDOMEN  AND  BACK. 

In  most  cases,  after  the  abdomen  has  been  opened,  we  expose  a 
mass  consisting  of  the  c£ecmn  and  coils  of  small  intestine  adhered  and 
matted  together  and  within  this  mass  the  appendix  and  abscess  are 
inclosed.  The  fingers  introduced  into  the  abdomen  can  be  passed 
freely  in  all  directions  between  the  inflammatory  mass  within  which 
the  abscess  is  located  and  the  anterior  abdominal  wall ;  inward  toward 
the  umbilicus,  upward  toward  the  liver,  and  downward  into  the  pelvis. 
Having  exposed  the  inflammatory  mass,  we  are  ready  to  evacuate  the 
abscess.  Before  doing  this,  however,  gauze  pads  are  tucked  into  the 
space  between  the  mass  and  the  anterior  abdominal  wall  in  order  to 
block  it  ofE  so  that,  when  the  abscess  is  opened,  the  entrance  of  pus 
into  the  general  peritoneal  cavity  will  be  prevented. 

The  abdominal  incision  is  held  open  with  retractors.  The 
appendix  is  not  seen,  being  buried  within  the  mass  of  matted  guts. 
We  can  locate  the  point  where  the  appendix  comes  off  from  the  csecum 
by  following  down  along  the  course  of  the  longitudinal  stri^  and  the 
abscess  is  opened  by  gently,  with  the  fingers,  working  between  the 
adhesions  until  the  abscess  is  reached.  As  the  pus  escapes  it  is 
swabbed  away  with  gauze  wipes.  The  abscess  cavity  is  wiped  out  dry 
with  pieces  of  folded  gauze  carried  on  holders. 

After  the  pus  has  been  evacuated  and  the  abscess  cavity  wiped  dry 
the  attempt  to  find  and  remove  the  appendix  may  be  made. 

The  search  for  and  effort  to  free  the  appendix,  especially  in  the 
hands  of  inexperienced  operators,  should  be  carried  on  in  a  careful 
manner  and  without  violence,  and  it  may  be  wise  in  exceptional  cases, 
where  unusual  difficulty  is  experienced  in  locating  and  separating  the 
appendix,  to  drain  the  abscess  cavity  and  leave  the  appendix  to  take 
care  of  itself  or  to  be  removed  later  after  suppuration  has  ceased,  thus 
giving  the  patient  the  best  chance  for  relief  from  his  immediate  danger. 
To  leave  the  diseased  appendix  subjects  the  patients  to  prolonged 
suppuration  and  the  danger  of  fecal  fistula.  There  is  no  question^ 
therefore,  as  to  the  desirability  of  removing  the  appendix  at  the  time 
that  the  abscess  is  opened  and  an  earnest  effort  should  be  made  to 
accomplish  this.  If  the  appendix  is  situated  to  the  inner  side  of  the 
csecum  or  behind  the  caecum  there  is  more  difficulty  in  separating  and 
removing  it  than  if  it  is  located  to  the  outer  side  of  the  caecum. 
Occasionally  the  appendix  has  no  mesentery,  it  is  applied  directly 
against  the  wall  of  the  caecum,  covered  over  by  the  peritoneal  layer  that 
invests  the  csecum.  Under  these  circumstances  it  may  be  necessary  to 
shell  the  appendix  out  of  its  bed  against  the  wall  of  the  caecum  after 


OPERATIONS  UPON  THE  VERMIF0R:M  APPENDIX.  485 

incising  or  tearing  through  the  serous  layer  that  covers  it.  In  those 
cases  where  the  mesentery  of  the  cgecuni  is  very  short  so  that  the  caecum 
cannot  be  drawn  into  the  incision  or  out  through  the  incision,  the 
location  and  separation  of  the  appendix  present  more  than  ordinary 
difficulty.  This  difficulty  can  be  partially  overcome  by  mobilizing  the 
cfecum  by  carefully  tearing  the  serous,  mesenteric  layers  that  bind  it  to 
the  posterior  wall  of  the  abdomen  and  that  resist  the  eiforts  to  deliver 
it  through  the  abdominal  incision.  The  manipulation  required  to 
detach  and  remove  the  appendix  will,  in  many  cases,  necessitate  break- 
ing up  the  protecting  adhesions,  but  this  is  without  serious  consequence 
if  the  abscess  has  been  pre^-iously  thoroughly  emptied  and  the  cavity 
swabbed  out  dry  with  gauze  wipes  on  holders.  At  times,  after  the 
pus  has  been  evacuated,  the  appendix  is  found  to  be  fairly  accessible 
and  may  be  felt  or  seen  in  the  abscess  cavity;  so  that,  by  farther 
separating  the  adhesions  with  the  fingers,  it  may  be  easily  reached 
and  removed.  A  fecal  concretion  which  may  have  escaped  from  a 
perforated  appendix  should  not  be  overlooked. 

In  many  cases  the  appendix  can  be  brought  up  so  that  its  mesen- 
terv  may  be  ligated  as  described  in  the  non-suppurative  cases.  In 
others,  in  order  to  get  the  appendix  out,  it  will  have  been  necessary 
to  tear  it  away  from  its  narrow  mesentery  or  to  shell  it  out  of  its 
serous  envelope,  especially  in  those  cases  where  the  appendix  has  no 
mesenten-  and  is  applied  directly  against  the  wall  of  the  cascum.  In 
many  of  these  cases  there  is  little  or  no  bleeding,  the  vessels  being 
thrombosed  to  a  considerable  extent.  Individual  bleeding  points  must 
be  clamped  and  ligatured. 

As  to  the  treatment  of  the  appendix  after  it  has  been  detached 
it  suffices  in  many  cases  to  simply  tie  a  catgut  ligature  around  the 
appendix  close  to  its  root,  say,  one-quarter  inch  distant  from  the 
caecum,  and  amputate  it  with  the  scissors  or  Paquelin.  The  stump 
which  is  steadied  with  the  ligature  left  long  for  the  purpose,  may  be 
sterilized,  if  the  appendix  has  been  amputated  with  the  scissors,  with  a 
drop  of  pure  carbolic  acid  on  a  probe  or  with  the  Paquelin.  If  con- 
ditions permit,  however,  it  is  preferable  to  amputate  the  appendix 
and  invert  the  stump  into  the  ca?cum,  securing  it  with  a  purse-string 
suture  of  chromic  catgut  as  described  for  the  non-suppurative  cases. 

These  abscess  cases  should  be  drained.  For  the  purpose  of 
drainage  a  cigarette  drain  of  plain  strip  gauze  encased  in  rubber 
tissue  or  gutta-percha  tissue  is  the  most  satisfactory.  It  emerges 
through  the  lower  end  of  the  incision.     If  the  suppurative  process 


486  ABDOMEN  AND  BACK. 

involves  the  connective  tissue  behind  tlie  colon  reaching  np  toward 
the  kidney,  the  question  of  a  counter-opening  in  the  loin  should  be 
considered.  The  writer  has  not  seen  the  necessity  for  this  additional 
counter-drainage. 

The  abdominal  incisian  is  closed,  except  below  where  the  drain 
emerges,  laj'-er  by  layer.  The  first  line  of  suture  of  plain  catgut  No. 
2  unites  the  edges  of  the  peritoneum  and  should  include  the  edges 
of  the  transversalis  fascia  to  give  a  more  secure  hold.  The  edges  of 
the  split  rectus  muscle  are  next  united  with  several  interrupted  sutures 
of  plain  catgut.  The  edges  of  the  aponeurosis  of  the  external  oblique 
are  brought  together  with  a  continuous  suture  of  chromic  catgut  and 
finally  the  edges  of  the  skin  are  approximated  .with  a, sufficient  number 
of  interrupted  sutures  of  silk-worm  gut.  The  incision  is  thus  closed 
except  for  the  small  opening  left  at  the  lower  end  where  the  cigarette 
drain  emerges. 

The  drain  should  be  pulled  out  for  part  of  its  length — an  inch 
or  two — at  the  end  of  forty-eight  hours.  On  the  third  day  the  drain 
is  pulled  out  altogether  and  replaced  by  a  thin  strip  of  iodoform  gauze. 

Operations  for  Appendicitis  Accompanied  by  General  Peritonitis 
or  Peritoneal  Infection  due  to  acute  gangrene  or  perforation  or  slough- 
ing of  the  appendix  before  adhesions  have  been  formed;  or  to 
rupture  or  leakage  of  an  appendicular  abscess.  In  these  cases  the 
appendix  should  be  removed  and  an  attempt  made  to  prevent  or 
check  the  general  peritoneal  infection. 

These  are  the  so-called  fulminating  cases  of  appendicitis  and  are 
frequently  overlooked,  and  may  go  unrecognized  until  the  general 
systemic  poisoning  has  reached  a  degree  which  is  in  itself  fatal  in 
spite  of  any  remedial  measures  that  may  be  undertaken  by  the  sur- 
geon. .  These  patients  frequently  do  not  complain  of  pain ;  they  may 
in&ist  that  they  are  feeling  better,  and  in  many  cases  they  exhibit  no 
elevation  of  temperature,  nor  acceleration  of  the  pulse  rate.  These 
patients,  however,  look  sick.  There  is  tenderness  over  the  region  of 
the  appendix,  the  tongue  is  coated,  the  breath  foul,  and  there  is  almost 
certain  to  be  the  characteristic  obstipation  that  is  not  relieved  by 
either  laxatives  or  enemas.  These  are  the  cases  where  delay  in 
operating  is  very  likely  to  occur  and  where  delay  is  most  fatal.  They 
must  be  operated  upon  before  the  heart  is  overwhelmed  by  the  poison. 

The  incision  is  made  through  the  rectus  muscle  in  a  manner 
similar  to  that  just  described  above,  and  should  be  sufficiently  long — 
four  to  six  inches. 


OPERATIONS  UPON  THE  VERMIFOR:\r  APPEXDIX.  487 

After  the  abdomen  has  been  opened  the  appendix  is  at  once 
sougbt  and  removed.  The  appendix  is  amputated  and  the  stump 
inverted  and  secured  with  a  purse.-string  suture  of  chromic  catgut. 
If  the  condition  of  the  appendix  is  such  that  it  wouki  be  difficult  or 
impossible  to  invert  the  stump  after  amputation,  it  will  suffice  to  tie  a 
catgut  ligature  around  the  root  of  the  appendix,  close  to  the  wall  of 
the  cax'um.  amputate  the  appendix  and  touch  the  stumj)  with  carbolic 
on  a  probe  followed  by  alcohol. 

The  fluids  in  the  neighljorliood  of  the  appendix  are  swabbed  out 
with  pieces  of  folded  gauze.  Fluids  in  other  adjacent  and  remote 
parts  of  the  abdomen  are  likewise  swabbed  away.  The  pelvis, 
where  fluids  are  especially  apt  to  gravitate  and  collect,  is  emptied 
by  repeated  swabbing  with  gauze  wipes  on  holders.  The  writer 
does  not  approve  of  irrigating  or  flushing  the  peritoneal  cavity  in 
these  cases.  If  the  intestines  are  coated  with  flaky  exudate  and 
matted  together  by  fresh  adhesions  it  is  advisable  to  separate  care- 
fully with  the  fingers  between  the  matted  coils  of  gut  in  order  to 
discover    and   evacuate    any    isolated    collections   of    purulent    fluid. 

For  the  purpose  ■  of  drainage  a  cigarette  drain  of  strip  gauze, 
wrapped  in  rubber  tissue  or .  gutta-percha,  is  introduced  into  the 
abdomen,  reaching  well  down  into  the  pelvis,  and  another  similar 
drain  is  introduced  which  reaches  down  to  the  region  of  the  appen- 
dix stump. 

The  incision  in  the  abdomen  is  closed  preferably,  layer  by 
layer,  as  described  in  the  preceding  operation,  leaving  the  lower 
end  open  to  an  extent  just  sufficient  for  the  drains  to  emerge. 
Where  haste  is  required  the  incision  may  be  closed  with  a  sufficient 
number  of  interrupted  sutures  of  silk  or  silk-worm  gut.  These 
sutures  are  introduced  after  the  edges  of  the  peritoneum,  including 
the  edges  of  the  transversalis  fascia,  have  been  united  with  a  con- 
tinuous suture  of  catgut.  The  interrupted  silk  sutures  include  all 
the  other  layers  of  the  abdominal  wall — the  skin,  aponeurosis,  and 
muscle — but  not  the  transversalis  fascia  or  peritoneum. 

Appendicostomy. — The  establishment  of  a  fistulous  opening 
through  the  appendix  into  the  cascum. 

This  plan  of  utilizing  the  appendix  was  suggested  by  Wier  for 
the  purpose  of  introducing  medicated  fluids,  solutions  of  nitrate  of 
silver,  etc.,  into  the  bowel  in  the  treatment  of  inflammatory  disease 
of  the  large  intestine,  ulcers,  etc. 

The  apendix  is  reached  in  the  usual  way  through  the  Mc- 
Burney  incision.    It  is  drawn  up  into  the  incision  and  secured  there 


488  ABDOMEN  AND  BACK. 

by  several  chromic  catgut  sutures  which  fix  its  mesentery  to  the 
edges  of  the  peritoneum  and  transversalis  fascia.  The  tip  of  the 
appendix  is  secured  to  the  edges  of  the  skin  with  one  or  two  sutures 
of  fine  chromic  catgut.  The  tip  of  the  appendix  is  amputated  and 
a  probe  introduced  to  discover  whether  the  lumen  is  patent  or  can 
be  dilated.  If  this  examination  shows  that  the  canal  is  free  a  cat- 
gut ligature  is  tied  around  the  open  end  of  the  appendix  in  order 
to  shut  it  off  for  one  or  two  days  until  adhesions  will  have  been 
formed. 

If  the  lumen  of  the  appendix  is  obstructed  or  obliterated  and 
does  not  permit  the  passage  of  the  probe  the  appendix  may  be 
amputated  and  its  stump  inverted  and  a  fistula  established  into 
the  caecum  according  to  the  plan  of  Gibson,  employing  the  procedure 
of  Witzel,  as  described  in  gastrostomy  for  this  purpose.  A  rubber 
tube  is  embedded  in  the  wall  of  the  caecum,  the  end  of  the  tube 
penetrating  the  wall  of  the  bowel  through  a  small  incision. 


THE    LIVER    AND    QALL=BLADDER. 

The  Surgical  Anatomy  of  the  Liver. — The  liver  is  a  solid  gland- 
ular organ  almost  completely  invested  by  the  peritoneum,  suspended 
in  the  upper  right  portion  of  the  abdomen  (right  hypoehondrium) 
and  extending  beyond  the  middle  line  into  the  left  side  (left  hypo- 
ehondrium). It  is  situated  under  cover  of  and  protected  by  the 
ribs,  except  in  the  epigastric  region.  Behind  and  toward  the  right 
the  liver  is  thick,  gradually  becoming  thin  toward  the  front  and 
left.  From  side  to  side  it  measures  eleven  inches;  from  before 
backward,  eight  inches;  and  its  posterior  border  has  a  thickness 
of  two  and  one-half  inches. 

Above,  the  diaphragm  separates  the  liver  from  the  pleura  and 
pericardium;  below  it  are  the  gall-bladder,  hepatic  flexure  of  the 
colon,  the  first  part  of  the  duodenum,  the  pylorus  and  stomach 
(which  it  overlaps),  and  the  right  kidney  and  suprarenal  capsule. 

The  superior  surface  of  the  liver  looks  forward  as  well  as 
upward,  and  is  in  relation  with  the  diaphragm  and  with  the  ribs  and 
costal  cartilages  from  the  fifth  or  sixth  to  the  tenth.  The  lower 
limit  of  this  surface  corresponds  to  the  free  border  of  the  ribs 
(costal  cartilages).  This  upper  surface  of  the  liver  is  smooth,  and 
presents  a  fold  of  peritoneum  running  from  the  anterior  border 
backward,  the  suspensory  ligament.  This  serves  to  suspend  the 
liver  to  the  diaphragm,  and  is  the  continuation  of  the  falciform  fold 


SURGICAL  ANATOMY  OF  THE  LIVER.  489 

of  peritoneum,  which  is  thrown  around  the  round  ligament  from 
the  anterior  abdominal  wall  and  which  extends  from  the  umbilicus 
to  the  anterior  edge  of  the  liver.  The  suspensory  ligament  divides 
the  upper  surface  of  the  liver  into  the  larger  right  lobe  and  the 
smaller  left  lobe;  the  latter  overlaps  the  stomach  and  reaches  to 
the  left  beyond  the  middle  line.  Toward  the  posterior  border  of 
the  liver  the  folds  of  the  suspensory  ligament  spread  out  right  and 
left,  and,  still  passing  between  the  liver  and  the  diaphragm,  form 
the  anterior  layer  of  the  coronary  ligament. 

The  posterior  border  of  the  liver,  really  a  surface,  is  thick, 
gradually  becoming  thin  toward  the  left,  and  is  not  covered  by 
peritoneum;  the  peritoneum  which  covers  the  upper  surface  of  the 
liver  upon  reaching  its  posterior  border  is  reflected  upward  to  the 
diaphragm  as  the  anterior  layer  of  the  coronary  ligament,  and  that 
which  covers  the  under  surface  upon  reaching  the  posterior  border 
of  the  liver  is  reflected  on  to  the  posterior  abdominal  wall  (dia- 
phragm), forming  the  posterior  layer  of  the  coronary  ligament.  The 
coronary  ligament,  at  either  end,  forms  the  right  and  left  lateral 
ligaments  of  the  liver.  The  posterior  border  of  the  liver,  to  the 
left  of  the  middle  line,  presents  a  notch  which  corresponds  to  the 
oesophagus  and  which  marks  the  division  of  the  liver  into  its  right 
and  left  lobes.  The  posterior  border  of  the  liver  is  in  relation  with 
the  diaphragm  and  lower  ribs,  with  the  vertebral  column,  tenth 
and  eleventh  dorsal,  the  aorta,  vena  cava  inferior,  etc.  The  oesoph- 
agus is  received  in  the  notch  above  mentioned. 

The  anterior  border  is  thin  and  in  many  patients  may  be 
palpated  through  the  abdominal  wall.  It  reaches  just  below  the 
free  border  of  the  ribs  (costal  cartilages),  and  corresponds  to  a 
line  drawn  from  the  tip  of  the  right  tenth  to  the  tip  of  the  left 
eighth  costal  cartilage,  where  this  joins  the  cartilage  of  the  seventh. 
In  women  the  anterior  edge  of  the  liver  is  found  well  below  the  free 
border  of  the  ribs  (costal  cartilages). 

The  under  surface  of  the  liver  is  irregular  and  marked  by 
grooves  and  impressions  for  the  colon,  gall-bladder,  kidney,  etc., 
and  is  covered  by  the  peritoneum,  which  is  reflected  downward  at 
the  transverse  fissure,  as  the  lesser  omentum,  as  far  as  the  lesser 
curvature  of  the  stomach,  where  its  folds  separate  to  include  the 
stomach  between  them. 

Besides  the  right  and  left  lobes,  the  under  surface  of  the  liver 
presents  three  smaller  lobes:  the  quadrate,  caudate,  and  the  lobus 
Spigelii.     The  large  right  lobe  is  marked  by  the  transverse  fissure. 


490  ABDOMEN  AND  BACK. 

which  passes  from  right  to  left  and  is  situated  rather  more  than 
half-way  back  from  the  anterior  border. 

At  this  fissure,  the  vessels,  ducts,  lymj^hatics,  and  nerves  pass 
in  and  out  of  the  liver.  These  structures  descend  in  the  right  free 
border  of  the  lesser  omentum,  between  its  two  folds,  the  common 
bile-duct  to  the  right,  the  hepatic  artery  to  the  left,  and  the  portal 
vein  between  and.  behind  these  two.  The  hepatic  duct,  which  is 
formed  by  the  junction  of  the  right  and  left  bile-ducts,  emerges 
from  the  right  end  of  the  transverse  fissure  and  descends  between 
the  folds  of  the  lesser  omentum,  where  it  is  Joined  by  the  cystic 
duct  to  form  the  common  bile-duct,  ductus  choledochus. 

If  we  examine  the  under  surface  of  the  liver  as  this  organ  lies 
in  its  normal  position  in  the  abdomen,  through  a  vertical  incision 
made  in  the  abdomen  from  the  tip  of  the  ninth  costal  cartilage,  we 
note,  in  sweeping  across  the  surface  from  right  to  left,  two  well- 
marked  grooves,  or  depressions,  into  which  the  finger  sinks;  the 
first,  that  toward  the  right,  corresponding  to  the  tip  of  the  ninth 
costaL  cartilage,  lodges  the  gall-bladder;  the  second,  nearer  the 
middle  line,  corresponds  to  the  round  ligament  (foetal  umbilical 
vein). 

The  Surgical  Anatomy  of  the  Gall-bladder  and  Bile-ducts.-— The 
gall-bladder  is  a  pear-shaped,  hollow-receptacle.  Its  wall  is  fairly 
thick  and  is  composed  of  muscle  and  mucous  membrane.  The  serous 
coat  (peritoneum)  invests  the  under  surface  of  the  body  and  all 
of  the  fundus  of  this  organ,  binding  it  to  the  under  surface  of  the 
liver.  The  peritoneum  is  reflected  downward  from  the  neck  of  the 
gall-bladder  to  the  duodenum  presenting  a  sharp  free  edge.  The 
cystic  duct  in  its  course  to  reach  the  common  duct  lies  between  the 
folds  of  this  reflection  of  peritoneum  a  short  distance  away  from 
its  free  edge.  The  gall-bladder  lies  in  direct  relation  with  the 
under  surface  of  the  liver, .  in  the  fossa  of  the  gall-bladder,  the 
apposed  surfaces  of  the  gall-bladder  and  liver  being  joined  to  each 
other  by  loose  connective  tissue. 

The  fundus  of  the  gall-bladder  is  directed  downward,  forward, 
and  to  the  right,  usually  appearing  below  the  anterior  thin  edge  of 
the  liver,  opposite  the  tip  of  the  ninth  costal  cartilage.  Sometimes 
it  does  not  reach  quite  as  far  as  the  anterior  edge  of  the  liver,  and 
is  then  concealed  underneath  the  liver.  The  edge  of  the  liver,  cor- 
responding to  the  fundus  of  the  gall-bladder,  is  sometimes  marked 
by  a  slight  notch. 

The  gall-bladder  is  three  to  four  inches  long  and  has  a  capacity 


SURGICAL  ANATOMY  OF  THE  GALL-BLADDER.  491 

of  about  one  and  one-half  ounces.  The  fundus  rests  upon  the 
transverse  colon,  and  the  neck  upon  the  first  part  of  the  duodenum. 
To  the  outer  side  of  the  gall-bladder — i.e.,  to  the  right — is  the 
hepatic  flexure  of  the  colon;  to  the  left  of  the  gall-ljladder  is  the 
pyloric  end  of  the  stomach.  The  neck  of  the  gall-bladder  is  bent 
upon  itself  like  the  letter  "S"  before  being  continued  into  the  cystic 
duct. 

The  cystic  duct  is  about  one-twelfth  inch  in  diameter  and  rather 
more  than  one  inch  in  length.  Its  lumen  has  such  an  irregular,  spiral, 
twisted  shape  that  the  passage  of  a  prol)e  through  it  is  diflicult  or 
impossible.  The  duct  curves  downward  between  the  layers  of  the 
peritoneal  fold  that  is  reflected  downward  from  the  neck  of  the  gall- 
bladder to  the  duodenum  and  just  above  the  first  part  of  the  duo- 
denum it  joins  Avitli  the  hepatic  duct  to  form  the  common  bile-duct. 
The  cystic  artery,  a  branch  of  the  right  bifurcation  of  the  hepatic 
passes  ujDward  and  toward  the  right  to  reach  the  neck  of  the  gall- 
bladder. In  its  course  to  reach  the  neck  of  the  gall-bladder  the  cystic 
artery  (with  its  accompanying  veins)  lies  above  and  to  the  left  of  the 
cystic  duct. 

The  hepatic  duct  is  one-sixth  inch  in  diameter  and  two  inches 
long;  it  is  formed  by  the  junction  of  the  bile-ducts  from  the  right  and 
left  lobes  of  the  liver.  The  right  bifurcation  of  the  hepatic  artery 
in  its  course  to  reach  the  right  lobe  of  the  liver  passes  to  the  right, 
behind  the  hepatic  duct,  just  above  the  point  where  the  cystic  duct  joins 
the  hepatic  to  form  the  common- duct. 

The  common  bile-duct,  ductus  communis  choledochus,  varies  in 
length :  it  is  usually  three  inches  long  and  one-fourth  inch  in  diameter ; 
it  continues  the  course  of  the  hepatic  duct,  descending  between  the 
folds  of  the  lesser  omentum,  lying  near  its  right  free  edge — the 
ligamentum  hepatico-duodenale.  In  this  situation  it  lies  in  front  of 
the  portal  vein  with  the  hepatic  artery  on  its  left  side;  continuing 
downward  it  passes  behind  the  first  part  of  the  duodenum,  and  finally 
behind  and  to  the  inner  side  of  the  second  part  of  duodenum,  between 
it  and  the  head  of  the  pancreas.  The  upper  part  of  the  common  duct 
is  known  as  the  supraduodenal  portion  and  is  rather  wider  than  the 
lower  part,  which  is  knowTi  as  the  retroduodenal  portion.  The  lower 
part  of  the  common  duct  is  imbedded  in  and  surrounded  by  the  sub- 
stance of  the  pancreas.  Pathological  processes  affecting  the  head  of 
the  pancreas,  chronic  pancreatitis,  tumors,  etc.,  might  cause  obstructive 
jaundice  by  compressing  the  common  duct.  The  common  duct  per- 
forates the  wall  of  the  second  part  of  the  duodenum  upon  its  inner 


492 


ABDOMEN  AND  BACK. 


side^  running  very  obliquely  in  the  wall  of  this  part  of  the  gut  for  a 
distance  of  from  one-half  to  three-fourths  inch.  That  portion  of  the 
duct  which  thus  obliquely  traverses  the  wall  of  the  duodenum  is  called 
the  intramural  part  of  the  duct.     The  orifice  of  the  duct  upon  the 


Fig.  227. — Bile  Ducts,  etc.  A  hole  cut  in  the  duodenum  to  show  the  papilla 
and  orifice  of  the  common  duct,  etc.  The  pancreas  is  outlined  behind  the 
stomach. 


inner  surface  of  the  gut  is  marked  by  a  papilla,  which,  as  a  rule,  is 
readily  recognizable  by  the  sense  of  touch  and  is  situated  about  three 
inches  distant  from  the  pylorus.  The  orifice  or  mouth  of  the  conamon 
duct  is  very  small,  permitting  the  introduction  of  only  a  fine  probe, 
2  mm.  in  diameter,  so  that  a  stone  that  has  succeeded  in  traversing  the 


OPERATIONS  UPON  THE  LIVER.  493 

whole  length  of  the  common  duct  may  become  impacted  at  the  orifice. 
Just  above  its  oritice  the  common  duct  is  dilated,  pouched,  and  this 
dilated  portion  is  known  as  the  ampulla  of  Vater. 

Usually  the  pancreatic  duct  terminates  in  the  ampulla  of  Vater. 
Under  these  conditions  the  pancreatic  duct  and  the  common  bile-duct 
have  the  same  common  opening  into  the  duodenum.  Less  commonly 
the  pancreatic  duct  opens  into  the  duodenum,  not  through  the  ampulla 
of  Yater,  but  independently,  through  a  separate  orifice  upon  the 
summit  of  the  papilla  that  marks  the  orifice  of  the  common  bile-duct. 

Attention  has  been  directed  by  Morison  to  the  space  in  the  upper 
part  of  the  abdomen  behind  the  liver,  into  which  the  gall-bladder 
presents.  It  is  bounded  above  and  anteriorly  by  the  right  lobe  of  the 
liver;  below  by  the  upper  or  ascending  layer  of  the  transverse  meso- 
colon; externally  by  the  abdominal  parietes  covered  by  the  parietal 
peritoneum ;  posteriorly  by  the  layer  of  the  transverse  mesocolon  which 
covers  the  upper  part  of  the  right  kidney  and  ascends  upon  the 
posterior  abdominal  wall.  Internally,  the  space  is  bounded  by  the 
peritoneum  which  is  reflected  over  the  bodies  of  the  vertebra?,  aorta, 
etc.  From  this  space,  following  down  along  the  gall-bladder  and 
cystic  duct,  one  can  pass  the  fingers,  behind  the  common  duct,  etc., 
through  the  foramen  of  Winslow,  into  the  lesser  cavity  of  the  perito- 
neum, i.e.,  into  the  peritoneal  space  behind  the  stomach. 


OPERATIONS    UPON    THE    LIVER. 

Hepatotomy. — Incision  of  the  liver  for  abscess,  hydatid  cyst,  etc. 

For  Abscess. — The  incision,  when  the  disease  involves  the  right 
lobe,  is  placed  along  the  outer  border  of  the  rectus  muscle,  extending 
from  the  tip  of  the  ninth  costal  cartilage  downward  for  a  distance  of 
from  three  to  five  inches  or  the  incision  may  be  made  below  and 
parallel  with  the  free  border  of  the  ribs. 

At  times  it  may  be  desirable  to  place  the  incision  elsewhere  in 
order  that  it  may  correspond  with  the  prominence  of  the  tumor  if  one 
is  present;  for  example,  if  the  abscess  is  located  in  the  left  lobe  of 
tlie  liver,  then  the  incision  is  better  placed  in  the  middle  line,  linea 
alba.  The  incision  is  carried  through  the  integument,  fascia,  etc., 
down  to  the  peritoneum  and  after  the  hemorrhage  has  been  controlled 
the  parietal  peritoneum  is  incised  between  two  mouse-tooth  forceps. 
We  may  find  the  tumor  adherent  to  the  parietal  peritoneum  and  in  this 
case,  after  aspirating  to  discover  the  nature  of  its  contents,  the  abscess 
is  incised  and  evacuated.     The  finger  is  introduced  into  the  abscess 


494  •        ABDOMEN  AND  BACK. 

cavity  to  explore  and  break  up  septa,  etc.  The  cavity  is  finally  packed 
with  strip  gauze.  Under  these  circumstances  the  operation  is  very 
simple  'and  there  is  no  danger  whatever  of  infecting  the  general 
peritoneal  cavity. 

In  some  cases  after  incising  the  peritoneum,  it  will  be  found  that 
the  tumor  is  not  adherent  to  the  parietal  peritoneum,  i.e.,  we  can  pass 
the  hand  freely  between  the  liver  surface,  tumor,  and  the  parietal 
peritoneum;  there  are  no  protecting  adhesions.  Under  these  con- 
ditions we  must  take  measures  to  prevent  contamination  of  the 
general  peritoneal  cavity  by  the  contents  of  the  abscess  cavity  while 
the'  cavity  is  being  evacuated  by  carefully  tucking  the  gauze  pads  in 
and  about  the  incision  before  opening  the  abscess ;  or  else  the  operation 
may  be  done  in  two  stages. 

Occasionally,  after  the  liver  has  been  exposed,  there  will  be  found 
no  external  signs,  softening  or  swelling  or  prominence  of  the  liver 
surface  to  indicate  the  site  of  the  abscess.  At  times  the  abscess  is 
situated  deep  in  the  substance  of  the  liver.  Under  these  circumstances 
it  will  be  necessary  to  resort  to  jDuncture  and  aspiration  to  locate  the 
abscess.  It  may  be  necessary  to  make  repeated  punctures  before  the 
abscess  is  discovered.  A  fairly  large  needle  should  be  used.  The  pus 
from  a  liver  aljscess  is  of  a  peculiar  dirty  reddish  color  and  one  should 
not  fail  to  recognize  it  or  mistake  it  for  blood. 

After  the  abscess  has  been  located  we  may  proceed  in  one  of  two 
ways.  Either  pack  down  to  the  surface  of  the  liver  with  strip  gauze, 
after  suturing  the  edges  of  the  peritoneum  to  the  edges  of  the  skin  in 
the  abdominal  incision  and  wait  for  two  or  three  days  until  adhesions 
have  formed  before  opening  into  the  abscess;  or  else,  after  placing 
the  gauze  pads  to  protect  the  peritoneal  cavity,  incise  and  evacuate  the 
abscess  at  once.     This  latter  method  is  probably  the  preferable  one. 

If  it  is  decided  to  open  immediately  the  gauze  pads  are  care- 
fully arranged  so  as  to  protect  the  peritoneal  cavity  from  contami- 
nation, and  a  small  incision  made  with  the  knife  into  the  abscess 
cavity.  The  pus  is  wiped  away  as  fast  as  it  escapes.  The  finger 
is  introduced  into  the  abscess  cavity  to  explore  and  break  up  septa 
and  to  remove  any  solid  pieces  of  necrotic  material  that  may  be 
present.  At  times  there  are  more  than  one  abscess  present.  They 
may  be  discovered  and  opened  by  the  examining  finger  during  the 
operation ;  at  times  they  are  overlooked  until  their  presence  is  indi- 
cated later  by  a  continuation  of  the  symptoms,  etc. 

The  abscess  cavity  is  wiped  dry  with  gauze  pads  and  finally 
packed  with  a  plug  of  strip  gauze.     The  gauze  pads  that  were  placed 


OPERATIONS  UPON  THE  LIVER.  495 

to  protect  the  peritoneal  cavity  are  removed,  and  the  incision  in 
the  abdomen  closed,  layer  by  layer,  except  where  the  gauze  drainage 
plug  emerges. 

For  Hydatid  Cyst. — 0]>eration  consists  in  evacuation  and  drain- 
age of  the  cyst  cavity.  Care  to  prevent  entrance  of  any  of  the 
contents  of  the  cyst  into  the  abdominal  cavity  during  the  course 
of  the  operation. 

Evacuation  and  drainage  may  be  done  in  one  or  two  stages. 

The  abdomen  is  opened  by  a  vertical  incision  corresponding 
to  the  position  of  the  tumor.  If  the  operation  is  to  be  done  in  two 
stages  the  incision  is  packed  with  strip  gauze  which  is  tucked  in 
between  the  liver  (tumor)  and  the  parietal  peritoneum.  After 
waiting  for  three  or  four  days  for  adhesions  to  form  between  the 
liver  and  peritoneum  that  will  serve  the  purpose  of  shutting  off 
the  peritoneal  cavity,  the  cyst  is  opened  and  contents  evacuated, 
the  lining  membrane  of  the  cyst  is  peeled  out  and  the  cavity  packed. 

If  the  operation  is  done  in  one  stage  then,  after  the  liver 
(tumor)  has  been  exposed,  the  peritoneal  cavity  is  carefully  packed 
off  by  gauze  pads  which  are  tucked  into  the  incision  and  the  cyst 
emptied  as  nearly  completely  as  possible  with  the  aspirator  or 
trocar.  The  cyst  is  then  incised  and  the  remaining  contents  com- 
pletely evacuated  and  the  lining  membrane  of  the  cyst  removed. 
The  edges  of  the  incision  in  the  cyst  are  sutured  to  the  edges  of 
the  peritoneum  and  transversalis  fascia  in  the  abdominal  incision, 
and  the  cyst  cavity  packed  with  strip  gauze. 

Transpleural  Route. — The  liver  may  be  exposed  through  an 
opening  which  is  made  in  the  lower  part  of  the  chest  incising  the 
two  layers  of  the  pleura  (that  which  lines  the  inner  aspect  of  the 
chest  wall  and  that  which  covers  the  surface  of  the  diaphragm)  in 
order  to  expose  the  diaphragm  for  incision.  This  route  is  some- 
times selected  for  the  purpose  of  draining  subphrenic  or  hepatic 
abscess,  hydatid  cyst,  etc. 

Corresponding  to  the  line  of  the  ribs  which  are  to  be  resected 
— the  seventh  and  eighth,  or  eighth  and  ninth,  or  ninth  and  tenth — 
an  incision  is  made.  This  incision  is  three  or  four  inches  long  and 
placed  in  the  intercostal  space  between  the  two  ribs  which  are  to 
he  resected.  As  to  the"  ribs  which  are  to  be  resected,  the  selection 
will  depend  upon  the  results  of  exploration  with  the  aspirating 
needle,  percussion,  etc.  These  means  determine  the  location  of 
the  pus,  etc.  The  middle  of  the  incision  will  correspond,  as  a  rule, 
to  the   axillarv  line,  mavbe   further   forward   or  more   toward   the 


496  ABDOMEN  AND  BACK. 

back,  according  as  the  puncture  with  aspirator  indicates  the  loca- 
tion of  the  pus,  etc. 

The  edges  of  the  skin,  etc.,  are  retracted  and  the  ribs  exposed 
by  an  incision  which  passes  along  the  length  of  each  of  the  two 
ribs  for  a  distance  of  two  or  three  inches,  and  which  penetrates 
through  the  periosteum  down  to  the  surface  of  the  bone.  "With  the 
periosteum  elevator,  the  soft  parts,  including  the  periosteum,  are 
peeled  off  the  surface  of  the  ribs  working  close  to  the  bone  and 
carefull}^  around  the  upper  and  lower  borders  and  posterior  surface. 
Two  or  three  inches  of  each  of  the  two  ribs  is  resected.  If  the 
intercostal  vessels  corresponding  to  the  upper  and  lower  borders 
of  the  ribs  are  injured  and  bleed,  they  are  clamped  and  ligated. 
Eeseetion  of  a  portion  of  one  rib  will  sui!ice  in  many  cases. 

The  intercostal  structures  (muscles)  are  incised,  spurting  ves- 
sels clamped  and  ligated  and  the  pleura  thus  exposed.  In  order  to 
prevent  the  entrance  of  pus,  blood,  etc.,  into  the  pleural  cavit}^,  it 
will  be  necessary  to  suture  the  two  layers  of  the  pleura  (that  which 
lines  the  inner  surface  of  the  chest  wall  to  that  which  covers  the 
diaphragm)  together  before  opening  the  abscess,  etc.  This  is  done 
with  a  continuous  suture  of  plain  catgut. 

The  diaphragm  is  finally  incised  and  the  pus,  fluids,  evacuated, 
and  a  drain  of  strip  gauze  introduced. 

Hepatectomy. — Excision  of  a  portion  of  the  liver.  Portions  of 
the  liver  have  been  excised  when  involved  primarily  or  by  extension 
from  growths  of  the  gall-bladder  and  ducts  either  by  means  of  the 
Paquelin  cautery  or  by  blunt  dissection  (enucleation)  with  the  finger. 
The  control  of  hemorrhage  is  the  essential  part  of  the  problem. 

If  the  Paquelin  cautery  is  used  it  should  be  at  a  dull  red 
heat  dividing  the  tissues  very  slowly.  With  the  Paquelin  used  in 
this  manner  there  is  not  overmuch  hemorrhage. 

According  to  the  method  of  Kousnetzotf  and  Pensky,  the  dis- 
eased portion  which  is  to  be  excised  may  be  isolated  by  introducing 
a  line  of  through-and-through  connecting  sutures  of  thick,  plain 
catgut  which  are  placed  well  beyond  the  outermost  limits  of  the 
part  which  is  to  be  excised.  These  sutures  are  tied  before  the 
diseased  portion  is  excised.  A  long  piece  of  catgut,  double,  is  used 
for  the  sutures,  which  are  introduced  with  a  long,  straight  or 
curved,  blunt-pointed  needle.  After  the  sutures  have  been  intro- 
duced the  loops  are  cut,  making  a  corresponding  number  of  indi- 
vidual sutures.  The  sutures  are  tied  very  slowly  and  not  sufficiently 
tightly  to  cut  through. 


OPERATIONS  UPON  THE  LIVER. 


497 


According  to  the  plan  of  Payr  and  Martina,  the  hemorrhage 
may  be  controlled  and  the  walls  of  the  defect,  which  is  left  after 
excision  of  the  diseased  portion  of  liver,  approximated  by  the  use 
of  penetrating  mattress  sntures  which  are  supported  by  being  car- 
ried through  perforated  magnesium  plates.  The  plates  are  placed 
on  either  side  of  the  edges  of  the  defect  which  is  left  in  the  liver 
after  the  diseased  portion  has  been  removed.  The  sutures  when 
drawn  tight  exert  a  distributed  compression   and   serve  to   control 


Fig.  22S.— The  Kousnetzoff  and  Pensky  Suture.  For  control  of  hemor- 
rhage from  the  liver.  The  loops  A  and  B  of  the  sutures  are  cut  to  make 
the  separate  ligatures  which  are  tied  alternately  upon  the  upper  and  lower 
surface  of  the  liver.  The  A  loops  are  cut  upon  the  upper  surface  and  the 
B  loops  upon  the  lower.  The '  blunt-pointed  needles  for  passing  the  sutures 
are  shown  in  the  upper  part  of  the  picture. 


the  hemorrhage  and  approximate  the  edges  of  the  wound.  In 
excising  the  diseased  portion  of  liver  the  section  can  be  made 
wedge  shape  by  cutting  into  the  liver  tissue  so  that  the  upper  and 
lower  edges  of  the  remaining  raw  space  in  the  liver  are  overhanging 
and  can  be  brought  together  with  suture  and  thus  do  away  with 
the  raw  surface  that  would  otherwise  remain.  The  plates  may  be 
applied  and  sutures  introduced  before  excising  the  diseased  portion. 
The  plates  are  placed  opposite  each  other  upon  the  upper  and  lower 


498 


ABDOMEN  AND  BACK. 


surfaces  of  the  liver,  and  the  sutures  introduced  and  drawn  tight, 
thus  compressing  the  liver  tissue  between  the  plates  and  preventing 
hemorrhage. 

The  plates  are  approximated  only  sufficiently  tight  to  control 
the  venous  hemorrhage.  Individual  spurting  arterial  points  are 
secured  and  ligated  with  catgut.     If  too  great  pressure  is  made  upon 


Fig.  229.  —  Control  of  Hemor- 
rhage from  the  Liver  {Payr  and 
Martina).  The  mattress  suture 
passed  through  the  liver  and  sup- 
ported by  the  magnesium  plates. 


Fig.  230.— Control  of  Hemorrhage  from 
the  Liver  {Payr  and  Martina). 


the  liver  between  the  plates  there  is  danger  of  necrosis  of  the  liver 
tissue,  and  resulting  pulmonary  erhbolism.  The  magnesium  plates 
are  absorbable. 

Tamponade  combined  with  suture  may  be  used  to  control  hem- 
orrhage in  wounds  of  the  liver.     The  edges  of  the  bleeding  space 


Fig.  231.— Ligature   Carrier   and   Needle   {Payr  and  Martina). 


in  the  liver  are  approximated  with  a  sufficient  number  of  inter- 
rupted sutures  of  catgut,  the  space  itself  being  packed  with  a  plug 
of  plain  strip  gauze. 

During  the  course  of  operations  or  in  wounds  of  the  liver, 
large  individual  bleeding  points  may  be  ligatured.  The  finger  is 
placed  upon  the  bleeding  point  to  control  the  hemorrhage  tem- 
porarily, and  a  ligature  carried  around  it  in  the .  substance  of  the 


OPERATIONS  UPON  THE  LIVER. 


499 


liver  with  a  cui-ved  needle.  The  ligature  is  carefully  and  slowly 
drawn  tight  and  tied.  Hemorrhage  from  individual  bleeding  points 
may  also  be  checked  by  direct  application  of  the  cautery  at  a  dull 
red  heat. 

Injuries  of  the  Liver. — The  liver  may  be  lacerated  by  blows  upon 
the  abdomen,  oftentimes  without  external  signs  of  injur}-  or  vio- 
lence or  by  fractured  ribs,  or  by  bodies  causing  penetrating  wounds. 
These  injuries  may  be  accompanied  by  free  hemorrhage.  On 
account  of  the  solid  structure  of  the  liver  large  venous  channels 
cannot  collapse,  and  thus  hemorrhage  is  favored.     Hemorrhage  may 


Fig.  232. — Control  of  Hemorrhage  from  the  Liver.     Suture  and  gauze 
pack  combined. 


be  controlled  by  the  cautery  or  by  packing,  or  by  packing  combined 
with  suture  of  the  edges  of  the  tear  in  the  liver.  The  several 
plans  for  the  control  of  hemorrrhage  from  the  liver  are  described 
in  the  preceding  paragraphs.  Hemorrhage  from  wounds  in  parts 
of  the  liver  which  are  inaccessible  for  suture,  etc.,  may  be  controlled 
by  gauze  pack. 

Omentopexy  (Talma). — This  operation  consists  in  attaching  the 
omentum  to  the  parietal  peritoneum.  It  is  performed  for  the  pur- 
pose of  establishing  compensatory  anastomosis  between  the  portal 
and  general  venous  systems.  In  addition  to  fixing  the  omentum  to 
the  parietal  peritoneum  it  is  desirable  at  the  same  time  to  induce 
adhesions  between  the  liver  and  spleen  and  the  con-esponding  peri- 
toneal surface  opposite  these  organs. 


500  ABDOMEN  AND  BACK. 

The  operation  is  recommended  for  the  relief  and  cure  of  ascites 
due  to  cirrhosis  of  the  liver,  and  if  one  may  judge  from  the  limited 
number  of  cases  that  have  been  reported  it  certainly  offers  a  pros- 
pect of  relief,  especially  if  undertaken  in  properly  selected  cases. 
The  ojaeration  should  not  be  done  in  those  cases  where  the  patho- 
logical changes  in  the  liver  have  progressed  to  an  extreme  degree. 

Normally  the  portal  and  general  venous  systems  communicate 
through  small  branches  that  are  located  in  the  subperitoneal  con- 
nective tissue  between  the  layers  of  the  hepatic  ligament;  these 
connect  branches  of  the  portal  vein  with  the  radicles  of  the  phrenic 
vein  and  azygos  major  veins.  A  large  branch  running  in  the  round 
ligament  from  the  liver  to  the  umbilicus  connects  the  left  branch 
of  the  portal  vein  with  the  epigastric  and  other  veins  in  the  abdomi- 
nal parietes;  these  veins  frequently  become  prominent  in  cirrhosis 
of  the  liver.  The  coronary  veins  which  drain  the  stomach  commu- 
nicate with  both  azygos  veins  through  the  oesophageal  plexus;  the 
veins  of  the  oesophageal  plexus  may  be  found  varieosed  and  may  be 
the  source  of  severe  hemorrhage  in  cirrhosis  of  the  liver.  The 
inferior  mesenteric  communicates  with  the  internal  iliac  through 
the  inferior  and  middle  hemorrhoidal  veins.  The  pancreatic  veins 
communicate  with  retro-peritoneal  venous  branches.  In  case  of 
obstruction  of  the  portal  circulation  caused  by  cirrhosis  of  the  liver 
the  means  of  communication  mentioned  above  are  not  sufficiently 
ample  to  relieve  the  obstructed  portal  system.  The  operation  of 
omentopexy  is  resorted  to  with  the  object  of  establishing  new  chan- 
nels of  communication  through  the  venous  branches  that  are  formed 
in  the  adhesions  between  the  attached  omentum  and  liver  and 
spleen  (portal  system)  and  the  peritoneum  (general  venous  system). 
It  may  be  observed  after  omentopex}^  that  the  superficial  veins  of 
the  abdomen  and  about  the  umbilicus  become  very  prominent  and 
smaller  veins  that  are  usually  invisible  are  plainly  to  be  seen. 

Incision  is  made  from  the  ensiform  process  to  the  umbilicus  in 
the  linea  alba  or  to  the  right  of  the  middle  line,  penetrating  between 
the  fibers  of  the  rectus  muscle.  When  the  abdomen  is  opened  the 
chief  bulk  of  the  fluid  escapes  and  the  rest  is  swabbed  out  with 
gauze  wijjes.     In  this  manner  the  abdominal  cavity  is  emptied. 

The  hand  is  introduced  into  the  abdomen  and  the  parts  exam- 
ined, especially  the  liver  and  spleen.  The  upper  surface  of  the 
liver,  and  the  outer  surface  of  the  spleen  and  the  corresponding 
portions  of  the  parietal  peritoneum,  that  covering  the  diaphragm 
opposite   the  liver  and  that  of   the   abdominal  wall   opposite   the 


OPERATIONS  UPON  THE  GALL-BLADDER.  501 

spleen,  are  vigorously  rubbed  with  a  rougli  piece  of  gauze  until 
there  is  a  slight  tendency  to  oozing.  The  parietal  peritoneum  for 
a  considerable  distance  upon  either  side  of  the  abdominal  incision 
is  treated  in  a  similar  manner.  The  great  omentum  is  then  sutured 
to  the  peritoneum  that  lines  the  anterior  abdominal  wall  for  some 
distance  upon  each  side  of  the  incision.  The  attachment  of  the 
omentum  to  the  anterior  abdominal  wall  should  be  suflficiently 
extensive  so  as  to  give  a  good,  broad  area  for  adhesions  to  form. 
Chromicized  catgut  should  be  used  for  suture  material. 

Some  surgeons  recommend  suturing  the  omentum  into  a  pocket 
made  for  the  purpose  between  the  parietal  peritoneum  and  the  trans- 
versalis  fascia. 

The  abdominal  incision  is  closed  layer  by  layer;  the  peritoneum 
with  plain  catgut  and  the  other  layers  with  interrupted  sutures  of 
chromic  catgut. 

The  Question  of  Drainage. — Drainage  has  been  resorted  to  to 
prevent  reaccumulation  of  fluid  during  the  time  that  the  adhesions 
are  forming,  etc.,  and  for  this  purpose  it  would  be  of  great  advantage ; 
but,  on  the  other  hand,  the  drainage  opens  the  way  to  fatal  peritoneal 
infection.  The  other  plan  which  is  probably  the  better  one  in  most 
eases,  is  to  omit  drainage  and  resort  to  tapping  after  the  operation, 
as  often  as  necessary  to  prevent  reaccumulation  of  fluid.  If  drainage 
is  employed  a  glass  or  rubber  tube  may  be  introduced  into  the  abdomen 
through  a  small  incision  made  for  the  purpose  in  the  lower  part  of 
the  abdomen  in  the  middle  line. 

OPERATIONS    UPON    THE    GALL=BLADDER. 

Aspiration  of  the  Gail-Bladder. — Drawing  off  the  contents  of  the 
gall-bladder,  usually  for  purposes  of  diagnosis.  This  operation  may 
be  resorted  to  in  order  to  determine  the  nature  of  a  tumor  which  can 
be  felt  through  the  abdominal  wall.  The  needle  is  introduced  over 
the  most  prominent  part  of  the  tumor,  usually  below  the  tip  of  the 
ninth  costal  cartilage,  and  some  of  the  contents  withdrawn.  The 
needle  should  be  of  small  caliber. 

This  is  a  dangerous  procedure  and  one  to  be  condemned,  even 
if  the  needle  and  skin  are  made  aseptic,  because  some  of  the  contents 
is  very  apt  to  escape  through  the  puncture  in  the  wall  of  the  gall- 
bladder upon  withdrawing  the  needle,  especially  if  the  needle  used  is 
not  of  fine  caliber. 

Cholecystotomy. — Incision  of  the  gall-bladder  for  the  purpose  of 
removing  stones.     The  incision  in  the  gall-bladder  is  closed  imme- 


502  ABDOMEN  AND  BACK. 

diately  after  stones,  etc.,  have  been  removed — the  "Ideal  Operation" 
of  Bernays.  This  is  an  operation  which  is  not  to  be  recommended 
except  in  occasional  cases  where  the  operator  is  quite  certain  that  the 
mucous  membrane  of  the  gall-bladder  is  healthy  and  that  the  bile- 
ducts — ^hepatic,  cystic  and  common — are  patent  and  unobstructed. 
Otherwise  the  incision  which  is  made  in  the  gall-bladder  should  be 
left  open  and  the  gall-bladder  drained — cholecystostomy. 

An  incision  is  made  which  reaches  from  the  tip  of  the  ninth  costal 
cartilage  vertically  downward  for  a  distance  of  four  inches.  It  pene- 
trates between  the  fibers  of  the  rectus  near  its  outer  border.  It  may 
be  necessary  in  stout  people  to  make  the  incision  longer.  Instead  of 
the  vertical  an  oblique  incision  may  be  used,  one  finger's  breadth 
distant  from  and  parallel  with  the  free  border  of  the  ribs,  the  middle 
of  the  incision  corresponding  to  the  tip  of  the  ninth  costal  cartilage. 
This  incision  is  usually  four  to  five  inches  long.  The  vertical  incision 
is  the  preferable  one. 

After  the  abdomen  has  been  opened  the  sharp  anterior  edge  of  the 
liver  is  seen  in  the  upper  part  of  the  incision  and  the  transverse  colon 
in  the  lower  part.  The  gall-bladder  may  also  be  seen,  more  or  less 
distended,  projecting  beneath  the  anterior  border  of  the  liver,  or  it 
may  be  small  and  concealed  beneath  the  edge  of  the  liver.  Occasionally 
in  order  to  expose  the  fundus  of  the  gall-bladder  and  bring  it  into  the 
incision,  it  is  necessary,  with  the  finger,  to  break  up  some  adhesions 
that  bind  the  gall-bladder  to  the  neighboring  organs.  If  stones  are 
present  they  may,  in  many  cases,  be  felt  through  the  wall  of  the  gall- 
bladder before  it  is  incised. 

Before  opening  the  gall-bladder  the  hepatic,  cystic  and  common 
ducts  should  be  examined  for  stones,  etc.  Occasionally  the  gall- 
bladder may  be  found  distended  to  such  a  degree  and  forms  such  a 
large  tumor  that  it  will  be  necessary  to  empty  it  with  the  trochar 
before  a  satisfactory  examination  of  the  ducts  can  be  made.  The  com- 
mon duct  may  be  palpated  between  the  two  fingers  of  the  left  hand 
introduced  into  the  foramen  of  Winslow  and  the  thumb  opposed  ante- 
riorly. A  normal  common  duct  may  not  be  made  out  readily  by  pal- 
pation, but  one  containing  a  stone  or  stones  and  especially  if  it  is 
dilated  and  its  wall  inflamed  and  thickened,  may  be  easily  reeognized. 

After  the  examination  of  the  ducts,  etc.,  has  been  completed,  the 
fundus  of  the  gall-bladder  is  seized  with  two  sharp-nosed  artery  clamps 
for  the  purpose  of  steadying  it.  Gauze  pads  are  tucked  into  the 
abdominal  incision  and  around  the  gall  bladder  in  order  to  protect  the 
peritoneal  cavity  against  leakage.     A  trochar   is   thrust  into   the 


OPERATIONS  UPON  THE  GALL-BLADDER.  503 

fundus  of  the  bladder  and  the  fluid  contents  drawn  off  as  nearly 
completely  as  possible.  The  organ  is  then  held  up  and  steadied 
with  the  artery  clamps  and  its  fundus  incised  and  any  remaining 
fluid  contents  swabbed  out  with  gauze  wipes.  Stones  that  are  pres- 
ent may  be  removed  with  a  scoop  or  force})S  and  the  finger  intro- 
duced in  order  to  explore  the  interior  of  the  organ.  Care  must  be 
exercised  that  stones  impacted  in  the  neck  of  the  gall-bladder  or 
in  the  cystic  duct  are  not  overlooked.  They  can,  in  some  cases,  be 
forced  back  into  the  bladder  and  removed.  If  the  cystic  duct  has 
been  obstructed,  as  soon  as  the  obstruction  is  relieved  there  is  apt 
to  be  a  copious  flow  of  bile  from  the  cystic  duct  into  the  gall-bladder. 

After  the  gall-bladder  has  been  emptied  and  its  interior  swabbed 
out  dry' with  gauze  wipes,  it  may  be  temporarily  tamponed  with  strip 
gauze  and  the  bile-passages,  hepatic,  cystic,  and  common  ducts,  again 
carefully  examined  for  stone,  etc. 

After  the  operator  has' satisfied  hhnself  that  the  ducts  are  unob- 
structed and  if  the  contents  of  the  gall-bladder  were  not  purulent, 
the  incision  in  the  gall-bladder  is  closed  with  a  double  row  of  sutures. 
The  first  row  of  plain  catg-ut,  includes  all  the  layers  of  the  wall  of  the 
gall-bladder  except  the  mucous  membrane. 

This  first  line  of  suture  is  reinforced  by  a  row  of  silk  Lembert 
sutures  which  include  only  the  serous  and  muscular  coats  of  the  gall- 
bladder :  these  serve  to  Ijury  the  first  row  and  bring  the  adjoining 
serous  margins  of  the  incision  into  accurate  apposition.  The  incision 
in  the  abdomen  is  closed  layer  by  layer ;  first,  the  parietal  peritoneum 
and  transversalis  fascia  are  united  with  a  continuous  catgut  suture, 
then  the  edges  of  the  muscle  are  brought  together  with  several  inter- 
rupted catgut  sutures,  the  edges  of  the  aponeurosis  are  united  with  a 
continuous  suture  of  chromic  catgut  and  finally  the  edges  of  the 
skin  with  a  catgut  suture. 

Cholecystostomy. — The  establishment  of  a  fistulous  opening  in 
the  gall-bladder;  for  the  removal  of  calculi  and  for  the  purpose  of 
draining  the  gall-bladder  and  liver.  The  incision  which  is  made  in 
the  gall-bladder  for  the  removal  of  the  calculi  is  left  open  in  order  to 
provide  drainage. 

The  incision  in  practically  all  operations  i;pon  the  gall-bladder 
and  bile-ducts  is  at  the  beginning,  exploratory.  It  may  be  enlarged 
afterwards  as  the  necessity  presents  itself.  A  sand-bag  placed  under 
the  lower  dorsal  region  is  of  distinct  advantage  in  those  cases  where  it 
is  necessary  to  gain  good  access  to  the  deeper  bile  structures,  cystic  and 
common  ducts,  etc. 


504  ABDOMEN  AND  BACK. 

The  incision  commences  at  the  tip  of  the  ninth  costal  cartilage 
and  passes  downward  for  a  distance  of  four  inches;  it  penetrates 
between  the  fibers  of  the  rectus  near  its  outer  border.  In  stout  people 
the  incision  in  the  skin  and  fat  layers  may  be  made  considerably 
longer  to  permit  better  access  to  the  deeper  layers.  If  more  room  is 
required  the  incision  may  be  extended  according  to  the  plan  of  Eobson 
upward  and  inward  toward  the  ensiform  cartilage.  This,  however, 
is  rarely  necessary  unless  for  extensive  work  upon  the  ducts,  etc. 

After  the  abdomen  has  been  opened  the  gall-bladder  is  sought  and 
examined.  It  may  be  distended  and  more  or  less  enlarged  and  present 
into  the  incision,  or  it  may  be  small  and  contracted  and  concealed  up 
underneath  the  liver.  It  is  often  necessary  to  free  the  gall-bladder 
from  adhesions  that  bind  it  to  adjacent  organs,  transverse  colon,  duo- 
denum, stomach,  etc.  The  adhesions  are  at  times  very  dense,  com- 
pletely bury  the  gall-bladder  and  require  much  patience  to  separate 
them.  By  gentle  manipulation  this  can  be  accomplished  even  in  cases 
that  at  first  sight  appear  almost  hopeless.  Eoughness  in  this  step  of 
the  operation  might  result  in  tearing  one  of  the  adjacent  hollow  vicera. 

Gauze  pads  are  arranged  in  and  about  the  incision  to  protect  the 
parts  and  catch  escaping  fluids,  blood,  etc.  One  pad  should  be  care- 
fully packed  under  the  gall-bladder  and  liver,  down  into  the  right 
kidney  space. 

When  the  gall-bladder  ducts  have  been  freed  from  adhesions, 
the  gall-bladder,  cystic,  hepatic  and  common  ducts  and  head  of  the 
pancreas  are  carefully  examined.  For  the  purpose  of  palpation  of  the 
common  duct,  etc.,  two  fingers  of  the  left  hand  are  introduced  into 
the  foramen  of  Winslow,  behind  the  free  edge  of  the  lesser  omentum, 
and,  with  the  thumb  opposed  anteriorly,  the  entire  length  of  the  com- 
mon and  hepatic  ducts  can  be  satisfactorily  examined.  In  some  excep- 
tional cases  it  may  be  necessary  to  enlarge  the  abdominal  incision  in 
order  to  get  better  access  to  the  bile-ducts. 

After  the  examination  of  the  bile-ducts  has  been  completed  the 
gall-bladder  is  brought  up  into  the  incision  and  secured  by  catching 
its  fundus  with  two  sharp-nosed  artery  clamps,  one  on  each  side. 
The  trochar  is  thrust  into  the  gall-bladder  between  the  two  clamps 
and  the  bladder  emptied  as  nearly  completely  as  possible.  If  a  piece 
of  rubber  tubing  is  attached  to  the  end  of  the  trochar  the  contents  of 
the  gall-bladder  may  be  conducted  over  the  side  of  the  table  and 
thus  avoid  soiling  the  field  of  operation.  When  the  bladder  collapses 
stones  may  be  felt  within  it. 


Fig.  233. 


-Cholecystostomy.     Purse-string  to  close  incision  in  fundus  of  gall- 
bladder around  the  drainage  tube  has  been  introduced. 


Fig.  234.— Cholecystostomy.  The  purse-string  suture  has  been  tied  and  the 
incision  in  the  fundus  of  the  gall-bladder  closed  "water-tight"  around  the 
tube.  Two  sutures,  A  and  B,  have  been  introduced  in  the  wall  of  the  gall- 
bladder. They  catch  the  edges  of  the  peritoneum  and  deep  fascia  on  either 
side  of  the  Incision,  and,  when  tied,  serve  to  suspend  the  gall-bladder  close  to 
the  abdominal  wall. 


506  ABDOMEN  AND  BACK. 

While  the  bladder  is  steadied  with  the  clamps  an  incision  is 
made  in  the  fundus  sufficiently  large  to  remove  the  stones  and 
permit  the  introduction  of  the  finger  for  the  purpose  of  exploration. 

The  clamps  are  then  removed  and  re-applied  so  as  to  catch  the 
edges  of  the  opening  in  the  gall-bladder  and  the  stones  are  removed 
with  the  stone  scoop  or  forceps.  Stones  impacted  in  the  neck  of  the 
gall-bladder  or  cystic  duct  may  be  dislodged  and  forced  back  into 
the  bladder  by  manipulation  of  the  neck  of  the  gall-bladder.  They 
can  then  be  removed  with  the  scoop  or  seized  with  the  forceps.  If 
unsuccessful  in  the  effort  to  dislodge  stones  impacted  in  the  neck  of 
the  gall-bladder,  etc.,  it  would  be  necessary  to  resort  to  cholecystectomy, 
removing  the  gall-bladder  together  with  the  stone  impacted  in  its 
neck,  etc.,  or,  if  impacted  in  the  cystic  duct,  to  incise  the  duct  and 
remove  the  stones  (see  "Cysticotomy").  At  times,  stones  which  are 
overlooked  and  left  remaining  in  the  neck  of  the  gall-bladder  and 
cystic  duct  become  dislodged  spontaneously,  especially  if  the  bladder  is 
drained  (large-calibre  tube)  and  washed  out  occasionally  with  sterile 
olive  oil,  after  operation. 

After  all  the  stones  have  apparently  been  removed  the  bladder 
is  packed  temporarily  with  a  strip  of  gauze  and  the  cystic  and 
common  duct  again  carefully  palpated  to  make  certain  that  no 
stones  are  left  remaining  in  these  passages. 

The  gauze  strip  is  removed  from  the  bladder  and  the  final  step 
of  the  operation,  provision  for  drainage,  proceeded  with.  A  purse- 
string  suture  of  chromic  catgut  No.  1  is  applied  around  the  edge  of 
the  incision  in  the  gall-bladder.  This  suture  may  penetrate  the 
entire  thickness  of  the  wall  of  the  gall-bladder.  It  is  placed  fairly 
close  to  the  edge  of  the  incision  and  takes  a  good  secure  bite  with 
each  thrust  of  the  needle.  The  individual  stitches  of  the  purse-string 
should  be  rather  long — about  one-third  inch  apart,  so  that  it  will 
draw  the  edges  of  the  opening  in  the  gall-bladder  very  tight  around 
the  tube  which  is  introduced.  The  drainage  tube  is  of  rubber,  of 
large  calibre — one-third  to  one-half  inch  in  diameter.  The  tube  is 
introduced  into  the  gall-bladder  and  secured  with  a  single  suture  of 
plain  catgut,  which  passes  through  the  tube  and  the  edge  of  the 
incision  in  the  gall-bladder.  The  tube  has  an  opening  in  the  end 
and  another  large  opening  in  the  side  near  the  end.  Not  more 
than  one  and  one-half  inches  of  the  length  of  the  tube  is  inserted 
into  the  gall-bladder  in  order  that  its  end  may  not  impinge  against 
the  wall  and  thus  become  blocked.     When  the  purse-string  is  pulled 


OPERATIONS  UPON  THE  GALL-BLADDER.  507 

tight  and  tied  it  closes  the  incision  in  the  gall-bladder  "'■'water-tight" 
around  the  drainage  tube. 

The  abdominal  pads  are  now  removed  and  the  parts  cleansed 
with  a  gauze  wipe  wet  in  hot  saline.  If  the  bladder,  carrying  the 
drainage  tube,  can  conveniently  and  without  too  much  tension  be 
brought  up  into  the  abdominal  incision,  it  is  fixed  to  the  edges  of 
the  same  with  two  chromic  catgut  sutures  which  secure  the  wall  of 
the  gall-bladder,  one  above  and  the  other  below  the  place  where  the 
drainage  tube  emerges.  These  two  sutures  are  used  to  suspend  the 
gall-bladder  to  the  edges  of  the  abdominal  incision.  They  are  intro- 
duced through  the  edges  of  the  peritoneum  and  transversalis  facia,  and 
pick  up  the  wall  of  the  gall-bladder  as  they  pass  across  the  incision 
from  one  edge  to  the  other.  They  take  one  or  more  good  bites  in 
the  wall  of  the  gall-bladder,  but  do  not  penetrate  into  the  mucous 
membrane  layer.  They  are  left  long  and  are  not  tied  until  after 
the  suture  that  is  used  to  unite  the  edges  of  the  peritoneum  has  been 
introduced. 

If  the  sandbag  under  the  dorsum  has  been  used  this  is  removed 
before  beginning  the  closure  of  the  abdominal  incision.  The  suture 
that  is  used  to  approximate  the  edges  of  the  peritoneum  and  trans- 
versalis fascia  (the  transversalis  fascia  is  included  in  the  peritoneal 
suture  in  order  to  give  a  better  hold)  is  a  continuous  stitch  of  plain 
catgut.  It  commences  in  the  upper  end  of  the  incision  and  is  continued 
downward  as  far  as  the  point  where  the  drainage  tube  emerges,  where 
it  is  tied.  Another  similar  suture  commences  in  the  lower  end  of 
the  incision  and  is  continued  upward  as  far  as  the  point  where  the 
tube  emerges  and  is  there  tied.  The  two  sutures  that  suspend  the 
gall-bladder  are  then  tied.  The  edges  of  the  split  rectus  muscle 
are  approximated  with  several  sutures  of  plain  catgut.  The  edges 
of  the  aponeurosis  (anterior  sheath  of  the  rectus)  are  united  from 
above  downward  as  far  as  the  drainage  tube,  and  from  below  upward 
as  far  as  the  tube,  with  a  continuous  stitch  of  chromic  catgut. 
Finally  the  skin  is  sutured.  In  very  fat  patients  it  is  well  to  add  a 
number  of  heavy  silk  sutures  for  extra  support.  These  are  introduced 
after  the  peritoneum  and  deep  fascia  have  been  sutured  and  the 
stitches  that  suspend  the  gall-bladder  have  been  tied.  They  are  placed 
about  one-half  inch  apart  and  pierce  all  the  layers  of  the  abdominal 
wall  except  the  peritoneum  and  deep  fascia.  These  extra  supporting 
sutures  are  not  tied  until  after  the  several  layers  of  the  incision  have 
been  sutured  as  described  above. 


508  ABDOMEN  AND  BACK. 

In  some  cases  it  is  not  feasible  to  suspend  the  gall-bladder  to 
the  edges  of  the  abdominal  incision  as  described  above,  owing  to 
the  fact  that  it  cannot  be  brought  up  into  the  incision  without 
undue  tension.  In  these  cases  the  gall-bladder  carrying  the  drain- 
age tube  ma)^  be  dropped  back  into  the  abdomen.  This  may  be 
safely  done,  especially  if  the  opening  in  the  bladder  has  been  care- 
fully sutured,  "water-tight'^  around  the  drainage  tube.  A  strip  of 
plain  gauze  packing  is  introduced  into  the  abdomen,  down  alongside 
the  drainage  tube  as  far  as  the  fundus  of  the  gall-bladder  "in  order 
to  provide  drainage  in  the  event  of  leakage. 

Cholecystectomy. — Extirpation  of  the  gall-bladder. 

The  gall-bladder  is  excised  in  cases  of  rupture  due  to  trau- 
matism, falls,  blows,  run-over.  Gall-bladders  that  are  affected  with 
malignant  disease;  gangrenous  or  perforated  as  the  result  of  acute 
inflammatory  processes;  shrunken,  contracted,  bound  down  and 
buried  beneath  dense  adhesions;  those  that  cannot  be  utilized  for 
drainage  of  the  liver  on  account  of  torsion,  kinking  or  stricture  of 
the  cystic  duct;  where  calculus  cannot  be  dislodged  from  its  posi- 
tion in  the  neck  of  the  gall-bladder  or  in  the  cystic  duct;  where  a 
biliary  fistula  persists  on  account  of  stricture,  obstruction,  etc.,  of 
the  cystic  duct.  Under  any  of  the  conditions  above  enumerated 
the  gall-bladder  should  be  extirpated. 

In  those  cases  where  the  gall-bladder  is  excised  the  operator 
should  be  certain  that  the  common  duct  is  patent. 

In  operations  upon  the  common  duct  where  drainage  of  the 
liver  is  desirable,  the  gall-bladder,  if  the  cystic  duct  is  patent,  can 
be  utilized  for  this  purpose  with  very  satisfactory  results.  The 
gall-bladder  and  unobstructed  cystic  duct  form  an  excellent  drain- 
age tract  from  the  liver.  If  drainage  of  the  liver  is  required  and 
at  the  same  time  it  is  necessary  to  remove  the  gall-bladder  on 
account  of  disease,  then  the  drainage  of  the  liver  must  be  provided 
by  immediate,  direct  drainage  of  the  common  duct. 

The  incision  is,  in  the  beginning,  exploratory,  and  is  made  from 
the  tip  of  the  ninth  costal  cartilage  downward,  as  described  in 
cholecystostomy.  The  primary  incision  is  supplemented  by  extending 
it  upward  and  inward  parallel  with  the  free  border  of  the  ribs  toward 
the  ensiform  cartilage.  A  sandbag  is  placed  under  the  lower  dorsal 
region.  By  these  means  the  deeper  bile  structures  are  brought  up 
nearer  to  the  abdominal  incision  and  the  abdominal  viscera  tend  to 
gravitate  toward  the  lower  part  of  the  abdominal  cavity. 


OPERATIONS  UPON  THE  GALL-BLADDER. 


509 


Fig.  235. — Cholecystectomy.  The  liver  has  been  drawn  out  of  the  incision. 
The  peritoneum  has  been  incised  and  the  cystic  duct  clamped  double  and 
divided  between  the  clamps. 


510  ABDOMEN  AND  BACK. 

After  the  abdomen  has  been  opened  the  gall-bladder  is  sought 
and  examined.  It  may  be  distended  and  present  into  the  incision 
or  it  may  be  small,  shrunken,  contracted,  concealed  up  under  the 
liver  and  buried  in  dense  adhesions.  It  is  necessary  to  separate 
the  adhesions  that  bind  the  gall-bladder  to  the  adjacent  organs, 
transverse  colon,  great  omentum,  duodenum,  stomach.  At  times 
the  adhesions  are  very  extensive  and  dense  and  require  much  care 
and  patience  to  separate  them  and  free  the  gall-bladder. 

The  gauze  pads  are  properly  placed  so  as  to  protect  the  adjoin- 
ing parts,  one  packed  down  under  the  liver  into  the  right  kidney 
space.  The  liver  and  with  it  the  gall-bladder  is  drawn  down  from 
under  the  ribs  out  through  the  incision,  and  the  liver  rotated, 
so  that  the  gall-bladder  comes  to  look  forward  and  upward.  The 
parts  are  then  readily  accessible  for  examination.  The  gall-bladder 
and  the  gall-ducts,  cystic,  common,  hepatic,  and-  the  head  of  the 
pancreas  are  carefully  palpated  and  inspected  as  far  as  possible, 
for  the  presence  of  stones,  malignant  disease,  etc.  With  two  fingers 
of  the  left  hand  introduced  into  the  foramen  of  Winslow,  and  the 
thumb  apposed  anteriorly,  the  entire  length  of  the  common  and 
hepatic  ducts  can  be  palpated. 

The  gall-bladder  may  be  separated  from  the  under  surface  of 
the  liver  and  removed  by  either  of  two  methods.  Commencing 
anteriorly  at  the  fundus  and  working  backward,  tying  the  cystic 
duct  and  the  cystic  artery  and  vein  as  the  final  step  of  the  pro- 
cedure; or  else  commencing  behind,  first  clamp  and  divide  the  cystic 
duct  and  ligate  the  cystic  artery  and  vein  and  then  work  forward 
toward  the  fundus. 

The  second  method  is  the  preferable  one,  especially  in  those  cases 
where  the  cystic  duct  is  fairly  accessible.  The  liver  and  gall-bladder 
are  held  up  and  the  cystic  duct,  where  it  joins  the  common,  clearly 
recognized.  The  peritoneal  layer  that  encloses  the  cystic  duct  is 
incised  and  the  duct  seized  with  a  long  clamp  within  one-half  inch  of 
its  termination  in  the  common.  A  second  clamp  is  applied  to  the 
duct  a  short  distance  from  the  first  and  between  the  two  clamps  the 
duct  is  divided.  The  stump  of  the  duct  is  ligated  with  chromic  catgut 
and  the  clamp  removed.  The  cystic  artery  and  vein  are  next  found 
above  and  to  the  left  of  the  duct.  Two  clamps  are  applied  and  the 
vessels  divided  between  them  and  the  ends  of  the  vessels  ligated  with 
catgut  and  the  clamps  removed. 

The  stump  of  the  cystic  duct  is  steadied  with  the  ligature  which 


OPERATIONS  UPON  THE  GALL-BLADDER.  5II 

was  left  long  for  this  purpose,  and  sterilized  with  a  drop  of  carbolic 
on  a  probe  or  with  the  Paquelin  and  the  ligature  cut  short.  The 
stump  of  the  duct  is  buried  beneath  the  peritoneum,  which  is  sewed 
over  it  with  several  fine  chromic  catgut  sutures. 

The  gall-bladder  is  enucleated  with  the  finger  from  its  bed  upon 
the  under  surface  of  the  liver.  The  peritoneal  layer  which  corresponds 
to  the  serous  coat  of  the  gall-bladder,  and  which  holds  the  gall-bladder 
in  its  position  against  the  under  surface  of  the  liver,  is  split  with  the 
scissors  as  the  enucleation  proceeds.  As  much  of  the  peritoneal  cover- 
ing of  the  gall-bladder  as  possible  is  preserved  to  be  used  later  for  the 
purpose  of  covering  over  the  raw  surface  of  the  liver  which  is  left 
after  the  gall-bladder  has  been  removed.  There  may  be  some  hemor- 
rhage from  the  raw  surface  of  the  liver.  This  is  controlled  usually  by 
pressure  with  a  ver}-  hot,  wet,  gauze  pad. 

The  free,  hanging  edges  of  the  peritoneum  which  are  left  after 
the  bladder  has  been  removed  are  united  with  a  continuous  suture  of 
plain  catgut,  and  thus  the  raw  surface  of  the  liver  is  covered  over. 

The  separation  of  the  gall-bladder  from  the  under  surface  of  the 
liver  may  be  commenced  anteriorly  at  the  fundus.  Snipping  the  fold 
of  peritoneum  that  is  reflected  from  the  under  surface  of  the  liver  over 
to  the  fundus  of  the  gall-bladder,  the  finger  is  introduced  and  the  gall- 
bladder detached  from  the  under  surface  of  the  liver  backward  toward 
the  neck  of  the  gall-bladder  and  cystic  duct.  The  fold  of  peritoneum 
that  covers  the  gall-bladder  is  incised  with  the  scissors  as  the  separa- 
tion of  the  gall-bladder  proceeds.  The  bladder  finally  hangs  by  its 
pedicle,  which  consists  of  the  cystic  duct  and  the  cystic  artery  and 
vein.  The  pedicle  is  seized  with  two  clamps  and  divided  between 
them.  The  stump  is  ligated  with  chromic  catgut,  the  clamp  removed, 
and  the  end  of  the  cystic  duct  treated  with  carbolic  on  a  probe  or  with 
the  Paquelin.  The  peritoneum  is  sewed  over  the  stump  as  described  in 
the  preceding  operation,  and  the  raw  surface  of  the  liver  covered  by 
uniting  the  free  hanging  edges  of  the  peritoneal  layer,  which  are  left 
after  enucleating  the  gall-bladder,  with  a  continuous  catgut  suture. 

If  drainage  is  not  necessar}^  the  abdominal  incision  is  closed  layer 
by  layer. 

If  desirable  to  drain  the  site  of  the  operation  a  plug  of  strip 
gauze  is  left  in  the  abdomen.  It  may  be  fixed  to  the  stump  of  the 
pedicle  with  a  single,  fine,  plain  catgut  suture.  The  incision  is  closed 
except  for  the  small  opening  left  for  the  drainage  plug  to  emerge. 
The  drain  is  usuallv  removed  after  two  or  three  davs. 


512  ABDOMEN  AND  BACK. 

If  it  is  desirable  to  drain  the  liver,  cholangitis,  the  stump  of  the 
cystic  duct  is  not  ligated.  The  clamp  is  removed  and  the  stump  of 
the  cystic  duct  is  split  down  as  far  as  its  junction  with  the  hepatic,  an 
opening  being  made  large  enough  to  admit  a  rubber  tube,  one-third  to 
one-half  inch  in  caliber.  The  tube  is  passed  through  the  split  stump 
of  the  cystic  duct  upward  into  the  hepatic  duct  for  about  one  inch  and 
is  secured  near  the  edge  of  the  incision  in  the  duct  by  a  single  catgut 
suture.  This  suture  catches  the  wall  of  the  duct  a  short  distance  away 
from  the  edge  of  the  incision  which  admits  the  tube.  A  plug  of 
gauze  is  packed  down  alongside  of  the  drainage  tube  to  the  incision 
in  the  duct  in  order  to  provide  drainage  in  the  event  of  leakage  around 
the  rubber  tube. 

Cholecyst-enterostomy. — The  establishment  of  a  fistulous  com- 
munication between  the  gall-bladder  and  the  intestinal  canal.  The 
operation  is  indicated  in  cases  of  inoperable  obstruction  of  the  common 
duct,  as  for  example,  new  growths  in  the  common  duct  or  head  of  the 
pancreas.  A  communication  is  established  that  permits  the  bile  to 
escape  from  the  gall-bladder  into  the  intestinal  canal.  The  operation 
would  likewise  be  indicated  in  case  of  persistent  biliary  fistula  provided 
the  reason  for  the  non-closure  of  the  fistula  were  due  to  some  inoperable 
obstruction  of  the  common  duct. 

The  communication  may  be  established  between  the  gall-bladder 
and  the  duodenum,  jejunum  or  large  intestine. 

The  cystic  duct  must,  of  course,  be  patent  so  that  the  bile  can 
find  its  way  into  the  gall-bladder. 

Cholecysto-duodenostomy. — The  formation  of  a  fistulous  opening 
between  the  gall-bladder  and  the  duodenum.  The  upper  part  of  the 
duodenum,  that  which  adjoins  the  gall-bladder  is  used  for  the  purpose. 
This  operation  has  an  advantage  over  those  that  establish  communica- 
tion with  the  jejunum  and  colon  in  that  it  permits  the  bile  to  enter 
the  upper  part  of  the  duodenum  where  it  may  be  used  to  good  purpose 
in  the  process  of  digestion. 

The  operation  may  be  made  with  the  suture,  clamp,  Murphy  but- 
ton, McGraw  rubber  ligature,  etc. 

Suture  Method. — A  vertical  incision  four  to  six  inches  long  is 
made  from  the  tip  of  the  ninth  costal  cartilage,  downward,  through 
the  outer  part  of  the  rectus  muscle.  If  necessary  to  get  more  room 
the  incision  may  be  extended  upward  and  inward,  toward  the  ensi- 
form  cartilage. 

Having  cut  through  the  abdominal  wall  the  liver  is  drawn 
down  and  out  of  the  incision  and  rotated  so  that  the  gall-bladder 


OPERATIONS  UPON  THE  GALL-BLADDER.  513 

comes  into  view.  Gauze  pads  are  properly  placed  in  the  incision 
and  about  the  gall-bladder  to  protect  the  parts  and  the  gall-bladder 
emptied  with  the  trochar  as  nearly  completely  as  possible,  and 
then  opened  through  a  small  incision  in  its  fundus.  Through  this 
incision  stones  are  removed  and  the  interior  of  the  gall-bladder, 
patency  of  the  cystic  duct,  are  investigated.  The  gall-bladder  is 
wiped  out  dry  and  packed  with  strip  gauze  to  prevent  leakage  dur- 
ing the  subsequent  steps  of  the  operation.  The  duodenum  is  located 
and  drawn  into  the  incision.  It  may  be  necessary  to  partly  detach 
the  duodenum  (see  mobilization  of  the  duodenum,  "Gastro-duo- 
deijostomy,"  Kocher,  page  438)  before  it  can  be  brought  up  with 
sufficient  freedom  into  the  incision  to  permit  of  easy  union  with 
the  gall-bladder.  The  duodenum  is  cleared  of  its  contents  by  gentle 
stripping  and  a  clamp  with  elastic  rubber-sheathed  blades  applied 
in  order  to  prevent  re-entrance  of  contents. 

The  gall-bladder  is  sutured  to  the  wall  of  the  duodenum  with 
a  continuous,  non-penetrating  stitch  of  silk  for  a  distance  of  one 
and  one-half  to  two  inches  in  a  manner  similar  to  that  described  in 
"Gastro-jejunostomy,  Suture,"  page  442.  This  line  of  suture  forms 
the  posterior  half  of  the  "outside  serous  ring"  suture.  The  needle 
still  carrying  the  thread  is  laid  aside  until  needed  later  to  intro- 
duce the  anterior  half  of  this  "outside  serous  ring"  suture.  The 
gall-bladder  and  duodenum  are  incised.  The  incisions  are  made 
parallel  with  and  about  one-quarter  inch  distant  from  the  suture 
line.  The  edges  of  the  incisions  are  sewed  to  each  other  all  around 
with  a  continuous  suture  of  plain  catgut.  Finally  the  needle  with 
which  the  posterior  half  of  the  "outside  serous  ring"  suture  was 
introduced  and  still  carrying  the  silk  thread,  is  again  taken  in  hand 
and  with  it  the  anterior  half  of  the  non-penetrating  suture,  "out- 
side serous  ring,"  is  applied,  and  this  step  of  the  operation  thus 
completed.     The  clamp  is  removed  from  the  duodenum. 

The  incision  in  the  fundus  of  the  gall-bladder  is  closed  layer 
by  layer  as  described  in  cholecystotomy.  The  first  line  of  suture, 
of  plain  catgut,  includes  all  the  la^'ers  except  the  mucous  mem- 
brane and  serves  to  close  the  opening.  A  second  line  of  suture  of 
silk — a  continuous  Lembert  suture — which  secures  the  serous  and 
muscular  layers  only  is  applied  and  serves  to  bury  the  first  catgut 
suture  line  and  bring  the  serous  margins  of  the  incision  into  accu- 
rate apposition.  It  may  be  desirable  in  some  cases  to  leave  the 
incision  which  was  made  in  the  fundus  of  the  gall-bladder  open  in 
order    to    provide    drainage    temporarily    until    the    communication 

33 


514 


ABDOMEN  AND  BACK. 


■between  the  gall-bladder  and  duodenum  has  become  established. 
In  order  to  accomplish  this  purpose  a  rubber  drainage  tube  is 
secured  "water-tight"  in  the  incision  in  the  gall-bladder,  and  the 
bladder  disposed  of  as  described  in  cholecystostomy. 

The  incision  in  the  abdomen  is  closed  for  part  of  its  extent  or 
completely  according  as  the  gall-bladder  is  drained  or  not. 

With  Clamps. — The  cholecysto-duodenostomy  may  be  made 
with  the  assistance  of  the  holding  clamps  in  a  manner  analogous 
to  that  described  in  "Gastro-jejunostomy''  and  "Lateral  Intestinal 
Anastomosis,  Clamp  Method." 

With  Muephy  Button. — A  small  button  is  used.    This  method 


F.g.  236. — Cholecysto-duodenostomy  witti   Murphy   Button. 


has  the  advantage  of  being  quick  and  comparatively  simple.  It  is 
of  value  in  those  cases  where,  owing  to  adhesions,  disease,  etc.,  the 
parts  are  not  so  easily  accessible,  not  sufficiently  movable  as  to 
permit  of  the  manipulation  necessary  in  making  the  anastomosis 
with  the  suture. 

The  incision  is  similar  to  that  described  in  the  operation  in 
the  preceding  paragraphs.  The  abdomen  is  opened  and  the  gauze 
pads  properly  arranged  to  protect  the  parts  and  the  gall-bladder 
emptied  with  the  trochar.  The  duodenum  is  emptied  of  its  con- 
tents by  stripping  it  between  the  fingers,  and  a  clamp  with  elastic, 
rubber-sheathed  blades  applied  to  prevent  the  re-entrance  of  con- 
tents. It  may  be  necessary  to  mobilize  the  duodenum  in  order  to 
bring  it  and  the  gall-bladder  into  close  contact  (see  page  438). 
With  a  straight  needle  a  chromic  catgut  suture  is  introduced  in  the 


OPERATIONS  UPON  THE  GALL-BLADDER.  515 

wall  of  the  gut  in  the  fashion  of  a  purse-string.  Each  leg  of  this 
suture  should  include  about  one  and  one-half  inches  of  the  length 
of  the  gut  and  be  in  a  straight  line;  it  is  made  with  three  punc- 
tures of  the  needle,  each  bite  including  about  one-third  inch  and 
passing  through  the  entire  thickness  of  the  wall  of  the  gut;  the 
second  limb  of  the  suture  is  made  with  the  same  thread  in  the 
reverse  direction  parallel  with  the  first  and  distant  from  it  about 
one-half  inch,  finally  terminating  along  side  of  where  the  needle 
first  entered  in  commencing  the  suture.  Corresponding  to  the  point 
where  the  thread  turns  back  to  form  the  second  half  of  the  suture 
a  little  slack,  or  loop,  should  be  left.  With  the  ends  of  this  running 
stitch  the  first  loop  of  a  surgeon's  knot  is  taken.  The  gut  is  incised 
between  the  two  rows  of  suture  for  a  distance  corresponding  to  hvo- 
thirds  the  length  of  the  diameter  of  the  button  to  be  used  (Xo.  1 
or  3  preferable),  the  incision  thus  made  being  shorter  than  the 
suture  line.  The  method  of  applying  the  purse-string  suture  is 
similar  to  that  employed  in  '"'Lateral  Intestinal  Anastomosis"  (Fig. 
203).  The  male  half  of  the  button  is  slipped  into  the  incision  in 
the  gut  and  the  purse-string  drawn  tight  about  it  and  tied.  A 
similar  purse-string  suture  is  introduced  in  the  wall  of  the  gall- 
bladder at  a  convenient  point  near  the  fundus,  and  an  incision  made 
and  the  female  half  of  the  button  introduced  into  the  gall-bladder 
and  the  purse-string  drawn  tight  and  tied.  The  two  halves  of  the 
button  are  then  carefully  and  steadily  forced  together. 

It  may  have  been  necessary  to  make  an  incision  in  the  fundus 
of  the  gall-bladder  to  remove  stones;  to  investigate  the  interior 
of  the  bladder,  etc.  The  gall-bladder  is  disposed  of  as  described 
in  the  preceding  operation. 

If  the  bladder  is  not  drained  the  incision  in  the  abdomen  may 
be  closed,  layer  by  layer,  as  described  in  cholecystotomy. 

Cholecysto-jejunostomy — Suture  Method. — A  fistulous  opening 
is  made  between  the  gall-bladder  and  jejunum  in  those  cases  where 
the  duodenum  is  unavailable  on  account  of  its  being  too  firmly 
fixed,  involved  in  the  disease,  etc.,  to  permit  of  its  being  brought 
up  into  apposition  with  the  gall-bladder. 

A  vertical  incision,  four  to  six  inches  long,  is  made  through 
the  outer  part  of  the  right  rectus  muscle  and  commencing  above, 
just  below  the  free  border  of  the  ribs  at  the  tip  of  the  ninth  costal 
cartila'^'e.  If  more  room  is  required  the  incision  may  be  extended 
upward  and  inward  toward  the  ensiform  cartilage. 

Having  cut  through  the   abdominal  wall  the   distended  gall- 


516  ABDOMEN  AND  BACK. 

bladder  is  usually  found  presenting  in  the  incision.  Gauze  pads  are 
placed  about  the  parts  to  jDrotect  the  peritoneal  cavity,  and  the  gall- 
bladder emptied  as  nearly  completely  as  possible  with  the  trochar 
and  then  incised,  the  incision  being  made  in  the  fundus  and  suffi- 
ciently large  to  remove  stones  if  present  and  to  permit  investiga- 
tion of  its  interior,  etc.  The  gall-bladder  is  swabbed  out  dry  with 
gauze  wipes  and  packed  temporarily  with  strip  gauze  to  prevent 
leakage  during  the  subsequent  steps  of  the  operation. 

A  loop  of  the  jejunum  about  twenty  inches  away  from  its  com- 
mencement (see  "Gastro-jejunostomy^')  is  secured  and  brought  up, 
in  front  of  the  great  omentum  and  transverse  colon,  into  the  inci- 
sion in  the  abdominal  wall.  The  loop  of  gut  is  emptied  of  its 
contents  by  stripping  between  the  fingers  and  two  pieces  of  narrow 
tape  are  placed  about  it  to  prevent  re-entrance  of  contents.  With 
a  straight  needle  and  fine  silk  the  gall-bladder,  at  a  convenient 
point  near  its  fundus,  and  the  gut,  opposite  its  mesenteric  border, 
are  united  to  each  other.  This  stitch  takes  a  good,  broad  bite, 
including  the  serous  and  muscular  coats,  but  does  not  pierce  the 
whole  thickness  of  the  wall  of  either  organ.  The  gall-bladder  and 
jejunum  are  joined  together  in  this  way  for  a  distance  of  one  and 
one-half  to  two  inches.  This  suture  forms  the  posterior  half  of 
the  "outside  serous  ring."  The  needle  still  carrying  the  thread  is 
temporarily  laid  aside  and  an  incision,  one  to  one  and  one-half 
inches  long,  made  in  the  gall-bladder  and  in  the  intestine.  These 
incisions  are  made  parallel  with  and  about  one-quarter  inch  away 
from  the  line  of  suture.  The  edges  of  the  openings  are  sewed  to 
each  other  all  around  with  a  continuous  suture  of  plain  catgut, 
and  thus  the  communication  between  the  two  organs  is  effected. 
The  first  needle  carrying  the  fine  silk  thread  with  which  the  first 
half  of  the  "outside  serous  suture"  was  made,  is  again  taken  up 
and  the  second  half  of  this  "outside  serous  suture"  is  introduced. 

The  incision  which  was  made  in  the  fundus  of  the  gall-bladder 
for  the  purpose  of  emptying  it  and  removing  stones,  etc.,  is  dis- 
posed of  as  described  in  the  operations  in  the  preceding  paragraphs; 
it  may  be  left  open  and  drained  or  closed  with  a  double  row  of 
sutures. 

The  incision  in  the  abdomen  is  closed  in  part  or  completely 
according  as  the  gall-bladder  is  drained  or  not  (see  "Cholecys- 
tostomy"). 

This  anastomosis  may  also  be  effected  with  the  clamps.  Murphy 
button,  McGraw  rubber  ligature,  etc. 


OPERATIONS  UPON  THE  GALL-DUCTS.  517 

Cholecysto-colostomy. — The  establishment  of  a  fistulous  communi- 
cation betAveen  the  gall-bladder  and  colon.  This  operation  has 
been  done  in  cases  of  inoperable  obstruction  of  the  connnon  duct 
so  as  to  provide  an  exit  for  the  bile  to  escape.  The  technique 
of  this  operation  is  quite  similar  to  that  of  the  operations  just 
described.  The  suture  method,  clamps,  Murphy  button,  etc.,  may 
be  used  to  make  the  junction  between  the  gall-bladder  and  large 
intestine.  The  transverse  colon  is  found  immediately  adjacent  to 
the  gall-bladder  and  the  anastomosis  between  the  gall-bladder  and 
it  is  easily  elfectcd.  It  is  claimed  that  the  functions  of  the  patient 
do  not  suffer  from  thus  diverting  the  bile  away  from  the  small 
intestine.  The  objection  has  lieen  made  against  this  operation  that 
the  gall-bladder  and  secondarily  the  liver  are  more  apt  to  become 
infected  from  the  large  intestine,  colon  bacillus,  etc. 

OPERATIONS  UPON  THE  GALL=DUCTS. 

Occasionally  the  cystic  and  hepatic  ducts,  but  more  frequently  the 
common  duct,  are  the  object  of  surgical  operation;  for  the  purpose 
of  removing  stones  that  have  become  impacted  or  to  establish  a  new 
orifice  of  communication  between  the  obstructed  or  obliterated  ducts 
and  the  bowel. 

Cysticotomy. — Incision  into  the  cystic  duct  for  the  purpose  of 
removing  stones  impacted  therein. 

In  many  instances  calculi  impacted  in  the  neck  of  the  gall- 
bladder or  in  the  cystic  duct  can  be  dislodged  and  forced  back  into 
the  gall-bladder  by  manipulation  and  massage  of  the  neck  of  the 
bladder  and  then  removed  through  an  incision  in  the  bladder. 
Occasionally,  however,  stones  become  so  tightly  fixed  in  the  neck  of 
the  gall-bladder  or  in  the  cystic  duct  that  they  cannot  be  dislodged  by 
this  means.  In  these  cases  extirpation  of  the  gall-bladder  including 
the  stone  impacted  in  the  neck  or  in  the  cystic  duct  would  be  the 
most  satisfactory  procedure;  or  the  impacted  stone  might  be  left 
undisturbed  in  the  cystic  duct  and  the  gall-bladder  drained,  using  a 
large  drainage  tube,  three-quarters  inch  in  caliber,  in  the  hope  that 
the  stone  may  become  dislodged  spontaneously  or  through  the  assist- 
ance rendered  by  frequent  irrigation  subsequent  to  operation  with 
soap,  olive  oil,  etc. 

Stones  impacted  in  the  neck  of  the  gall-bladder  or  cystic  duct  may 
be  removed  through  incision  made  through  the  neck  of  the  gall- 
bladder or  cystic  duct  down  upon  the  stone.  The  incision  which  is 
thus  made  should  be  closed  with  a  row  of  non-penetrating  sutures  of 


518  ABDOMEN  AND  BACK. 

fine  chromic  catgut  and  the  gall-bladder  drained  (Cholecystostomy.) 

In  order  to  gain  access  to  the  cystic  duct  an  abdominal  incision 
and  measures  similar  to  those  described  in  cholesystectomy  are 
necessary. 

Hepaticotomy. — Incision  of  the  hepatic  duct,  for  the  purpose  of 
removing  impacted  stones.  Calculi  may  be  present  in  the  hepatic  duct 
and  may  become  impacted  there.  .As  a  rule  they  can  be  stripped  with 
the  fingers  into  the  gall-bladder  and  removed  through  an  incision  in 
the  gall-bladder;  or  they  may  be  stripped  down  into  the  common 
duct  and  removed  through  an  incision  in  the  common  duct.  When 
the  stone  is  firmly  impacted  it  becomes  necessary  to  cut  down  upon  the 
stone  through  the  wall  of  the  hepatic  duct  in  order  to  remove  it. 

When  the  stone  is  lodged  in  the  lower  part  of  the  hepatic  duct 
(just  above  the  point  where  the  hepatic  is  joined  by  the  cystic  to 
become  the  common  duct),  the  steps  of  the  operation  for  its  removal 
are  quite  similar  to  those  described  in  choledochotomy. 

The  upper  part  of  the  hepatic  duct  is  very  inaccessible  and  calculi 
impacted  in  this  part  of  the  duct  may  be  very  difficult  to  reach.  A 
free  abdominal  incision  is  required  and  it  may  be  necessary  to  break 
the  cartilages  of  the  seventh  and  eighth  ribs  at  their  junction  with  the 
ribs  to  gain  more  room.  The  liver  is  drawn  out  of  the  incision  and 
rotated  and  one  or  two  fingers  introduced  into  the  foramen  of  Winslow 
in  order  to  steady  the  hepatic  duct  and  draw  it  up  into  the  abdominal 
incision.  The  incision  in  the  hepatic  duct  through  which  the  stone 
is  removed  is  not  closed.  A  rubber  drainage  tube,  6-8  mm.  in 
diameter,  is  introduced  through  the  incision  and  pushed  up  into  the 
duct  as  described  in  detail  in  choledochotomy. 

Stones  impacted  in  the  hepatic  duct  may  be  removed  by  splitting 
the  cystic  duct  (with  or  without  extirpation  of  the  gall-bladder)  down 
as  far  as  its  junction  with  the  common.  Through  the  opening  thus 
made  the  stones  may  be  removed  from  the  hepatic  duct. 

Choledocliotoniy.  —  Incision  into  the  common  bile-duct.  This 
operation  is  performed  for  the  purpose  of  removing  calculi  which  have 
become  lodged  in  the  duct.  Calculi  may  become  impacted  in  any  part 
of  the  common  duct,  in  the  upper  supraduodenal  part,  in  the  lower 
retroduodenal  part  or  in  the  lower  end  of  the  duct,  in  the  intramural 
portion  or  in  the  ampulla  of  Vater — the  dilated  part  of  the  duct  just 
before  it  opens  into  the  duodenum.  There  may  be  only  one  calculus, 
frequently  there  are  several  or  they  may  be  very  numerous.  They  may 
be  lodged  loosely  in  the  common  duct  being  thus  able  to  change  their 
position  from  time  to  time  and  permitting  the  bile  to  flow  past  them, 


OPERATIONS  UPON  THE  GALL-DUCTS. 


519 


Fig.  237. — Choledochotomy.  Two  fingers  have  been  passed  into  the  foramen 
of  Winslow  and  the  common  duct  lifted  forward  into  the  abdominal  incision. 
An  incision  has  been  made  through  the  wall  of  the  common  duct  down  upon 
a  stone  contained  within. 


520  ABDOMEN  AND  BACK. 

or  they  may  be  impacted  so  snugly  in  the  duct  that  they  obstruct  the 
flow  of  bile  completely  and  cause  symptoms  accordingly. 

Supra-duodenal  Choledochotomy.  —  A  sand-bag  is  placed 
under  the  lower  dorsal  region  and  the  table  inclined  so  that  the  head 
is  five  or  six  inches  higher  than  the  foot. 

The  primary  incision  from  the  tip  of  the  ninth  costal  cartilage 
(eholecystostomy),  is  enlarged  by  carrying  it  upward  and  inward, 
parallel  with  the  free  border  of  the  ribs,  toward  the  ensiform  cartilage, 
for  a  distance  of  two  or  three  inches — Eobson  incision. 

After  the  abdomen  has  been  opened  the  protecting  gauze  pads  are 
tucked  into  the  incision  and  adhesions  carefully  separated  and  a  pre- 
•liminary  examination  made  of  the  gall-bladder  and  the  bile-ducts. 
The  ducts  are  palpated,  the  common  and  hepatic,  for  their  entire 
length,  with  two  fingers  in  the  foramen  of  Winslow  and  the  thumb 
opposed.  Calculi  that  are  present  in  the  ducts,  may  be  readily 
detected. 

The  liver  and  with  it  the  gall-bladder  is  drawn  down  from  under 
the  ribs  and  out  through  abdominal  incision  and  the  liver  rotated  so 
that  the  gall-bladder  comes  to  look  forward  and  upward  and  the  com- 
mon duct  is  brought  up  nearly  to  a  level  with  the  incision  in  the 
abdomen  and  may  be  examined  and  palpated  with  precision.  The 
common  bile-duct  with  the  portal  vein  behind  it  and  the  hepatic  artery 
upon  its  left  side  is  situated  between  the  folds  of  the  lesser,  gastro- 
hepatic,  omentum,  near  its  right,  free  border,  and  may  be  palpated  for 
its  entire  length  with  two  fingers  of  the  left  hand  in  the  foramen  of 
Winslow  and  the  thumb  opposed  anteriorly.  The  normal  common 
duct  may  not  always  be  recognized  but  if  there  are  stones  in  the  duct 
and  especially  if  the  duct  has  become  dilated  and  its  wall  thickened  it 
may  be  readily  recognized  by  the  examining  fingers  and  the  stones  felt 
within.  Several  lymph  nodes  which  are  situated  between  the  layers 
of  the  gastro-hepatic  omentum  near  its  right  free  edge,  may  be  felt 
and  might  be  mistaken  for  stones  in  the  common  duct,  especially 
as  they  are,  at  times,  found  enlarged  and  indurated  as  a  result  of 
disease  of  the  gall-duets  or  of  the  adjacent  organs. 

Before  proceeding  to  the  removal  of  the  stones  from  the 
common  duct,  the  gall-bladder  should  be  incised,  after  being  first 
emptied  with  the  trochar;  any  stones  that  are  present  in  the  gall- 
bladder are  removed  and  its  interior  swabbed  out  dry  with  gauze 
wipes.  The  gall-bladder  is  then  packed  temporarily  with  strip 
gauze  to  prevent  any  leakage  during  the  subsequent  steps  of  the 
operation. 


OPERATIONS  UPON  THE  GALL-DUCTS. 


521 


The  protecting  gauze  pads  are  again  properly  arranged,  one 
packed  carefully  down  under  the  liver  into  the  right  kidney  space 
and  the  operator  proceeds  to  remove  the  stones  from  the  common 
duct.  Two  fingers  of  the  left  hand  are  introduced,  behind  the 
common  duct,  into  the  foramen  of  Winslow  and  the  duct  drawn 
forward  toward  the  abdominal  incision  and  it  and  the  stone  within 
thus  steadied  while  an  incision  is  made  through  its  wall,  cutting 
directly  down  upon  the  stone.  The  incision  is  just  large  enough 
to  permit  the  extraction  of  the  stone.  When  the  stone  is  removed 
bile  may  escape  and  is  wiped  away  as  fast  as  it  flows.  The  finger 
is  introduced  into  the  duct  or  a  probe,  if  the  duct  is  too  small  to 
admit  the  finger,  and  search  is  made  for  any  remaining  stones. 
The  finger  is  passed  upward  and  downward  in  the  duct  in  examining 
for  additional  stones.     At  times  calculi  are  impacted  low  down  in 


Fig.  238. — Method  of  Suturing  Incision  in  the  Common  Duct.  The  sutures 
appear  in  the  edges  of  the  incision  just  short  of  the  mucous  layer.  They  do 
not  penetrate  the  entire  thickness  of  the  wall  of  the  duct — they  do  not  pre- 
sent within  the  lumen  of  the  duct. 

the  duct  and  may  be  dislodged  and  worked  upward  into  the  upper 
part  of  the  duct  and  removed  through  the  incision. 

The  incision  in  the  common  duct  may  be  closed  with  a  con- 
tinuous or  several  interrupted  sutures  of  fine  chromic  catgut.  These 
sutures  enter  and  exit  close  to  the  edges  of  the  incision,  but  they 
must  surely  not  penetrate  the  mucous  layer — they  must  not  appear 
within  the  lumen  of  the  duct — they  appear  in  the  edges  of  the 
incision  just  short  of  the  mucous  layer.  As  to  the  advantage  of 
closing  the  incision  in  the  duct  there  is  considerable  difference  of 
opinion.  If  the  incision  is  closed  a  drain  made  of  strip  gauze 
wrapped  in  rubber  tissue  may  be  left  in  the  abdomen,  reaching 
down  to  the  suture  line  in  the  common  duct. 

Some  surgeons  leave  the  incision  in  the  duct  unsutured  and 
introduce  a  rubber  tube  into  the  duct  for  drainage;  especially 
should  this  be  done  if  there  have  been  symptoms  of  septic  liver 
infection — cholangitis.  If  the  duct  is  to  be  drained  a  rubber  tube 
is  passed  through  the  incision  and  upward  into  the  duct  for  about 


522  ABDOMEN  AND  BACK. 

one  inch  and  fixed  in  position  by  a  single  catgut  stitch  that  passes 
through  the  tube  and  picks  up  the  wall  of  the  duct,  but  without 
penetrating  its  entire  thickness,  close  to  the  edge  of  the  incision. 
If  the  incision  is  larger  than  is  necessary  to  accommodate  the  tube 
a  sufiicient  number  of  fine  chromic  catgut  sutures  are  taken  to 
close  the  incision  tightly  around  the  tube.  These  sutures  enter  and 
exit  close  to  the  edges  of  the  incision,  appearing  in  the  edges  of 
the  incision  just  short  of  the  mucous  layer.  They  must  not  pene- 
trate the  mucous  coat.  A  drain  of  strip  gauze  rolled  and  wrapped 
in  rubber  tissue  is  left  in  the  abdomen,  reaching  alongside  the 
rubber  drainage  tube  down  to  the  suture  line  in  the  duct. 

The  sandbag  is  removed  from  under  the  back  and  the  abdomi- 
nal incision  carefully  sutured,  layer  by  la3''er,  except  the  space  that 
is  left  open  for  the  exit  of  drainage  tubes,  etc.  The  peritoneum 
and  transversalis  fascia  are  sewed  together  with  a  continuous  suture  of 
plain  catgut;  the  edges  of  the  muscles  with  several  interrupted 
sutures  of  plain  catgut;  the  edges  of  the  aponeurosis  with  a  con- 
tinuous suture  of  chromic  catgut,  and  finally  the  skin. 

Eetro-duodenal  Choledochotomy. — Incision  of  the  retro- 
duodenal  portion  of  the  common  duct  for  the  purpose  of  removing 
calculi  impacted  there.  This  part  of  the  common  duct  is  embedded 
in  the  head  of  the  pancreas,  in  some  instances  completely  sur- 
rounded, by  pancreatic  tissue.  At  times  it  is  very  difficult  to  expose 
the  lower  part  of  the  duct  and  incise  it  without  dividing  the  pan- 
creatic tissue  which  surrounds  it,  and  possibly  wounding  the  duct 
of  Wirsung  which  lies  in  close  proximity  to  the  lower  part  of  the 
common  duct.  In  some  cases  a  stone  impacted  in  the  lower  part 
of  the  common  duct  can  be  dislodged  and  massaged  upward  into 
the  supraduodenal  portion  and  removed  through  an  incision  in 
this  part  of  the  duct,  as  indicated  in  the  operation  described  in  the 
preceding  paragraphs. 

The  preliminary  steps  of  the  operation,  incision,  etc.,  are  similar 
to  those  described  in  supraduodenal  choledochotomy. 

In  order  to  expose  the  lower  part  of  the  common  duct  the 
peritoneal  layer  is  incised  along  a  line  parallel  with  and  less  than 
an  inch  to  the  outer  side  of  the  second  part  of  the  duodenum,  and 
this  part  of  the  intestine  is  detached  from  the  posterior  abdominal 
wall  and  turned  over  toward  the  left  so  that  its  posterior  surface 
is  exposed.  The  lower  part  of  the  common  duct  is  sought.  The 
calculus  can  be  felt  distinctly  within  and  another  effort  should  be 


OPERATIONS  UPOX  THE  GALL-DUCTS.  523 

made  to  dislodge  it  and  force  it  up  into  the  supraduodenal  part 
of  the  duct,  where  it  can  he  easily  removed.  If  this  effort  is  not 
successful  an  incision  is  made  through  the  wall  of  the  duct  cutting 
directly  do'SATi  upon  the  stone  and  it  and  any  additional  calculi 
removed.  The  incision  in  the  duct  is  closed  with  several  non- 
penetrating sutures  of  fine  chromic  catgut  in  a  manner  similar  to 
that  descrihcd  in  supraduodenal  choledochotom}^,  and  the  displaced 
duodenum  returned  to  its  natural  position.  A  strip  of  gauze  rolled 
and  wrapped  in  ruhher  tissue  is  left  in  the  abdomen  reaching  down 
into  the  incision  Avhich  was  made  in  the  peritoneal  layer  alongside 
of  the  duodenum. 

It  is  necessary  to  provide  a  temporary  outlet  for  the  bile  while 
the  incision  in  the  lower  part  of  the  duct  is  healing,  either  by  direct 
drainage  of  the  common  duct  by  means  of  a  rub])er  tul^e  introduced 
through  an  incision  made  for  the  purpose  in  its  supraduodenal  part, 
or  else  by  draining  the  gall-bladder  (cholecystostomy)  if  it  is  cer- 
tain that  the  cystic  duct  is  unobstructed. 

Removal  of  Calculi  from  the  Common  Duct  through  the  Duo- 
denum.— For  calculi  which  are  impacted  low  down  in  the  duct  at  or 
near  the  point  where  it  enters  the  duodenum.  "The  Transduodenal 
Choledochotomy"  of  McBurney,  "The  Transduodenal  Choledoeho- 
duodenostomy"  of  Kocher. 

The  preliminary  steps  of  the  operation,  sand-bag  under  the 
lower  dorsal  region,  upper  end  of  table  raised  and  the  abdominal 
incision  are  similar  to  those  described  in  "Supraduodenal  Chole- 
dochotomy." 

After  the  abdomen  has  been  opened  the  gall-bladder  and  bile 
ducts  are  examined  and  the  stone  recognized  in  the  lower  part  of 
the  common  duct.  An  effort  should  be  made  to  dislodge  the  stone 
and  force  it  upward  into  the  supraduodenal  part  of  the  duct  where 
it  can  readily  be  removed,  or  possibly  into  the  duodenum.  This 
failing  we  proceed  to  remove  it  through  the  duodenum.  The  duo- 
denum may  be  made  more  accessible,  if  necessary,  by  loosening  it 
from  its  attachment,  "mobilizing"  it,  according  to  the  method  of 
Kocher. 

The  mobilization  of  the  duodenum  is  effected  by  making  a 
vertical  incision  through  the  posterior  peritoneal  layer,  about  one 
finger's  breadth  to  the  outer  side  of  the  second  part  of  the  duo- 
denum. This  incision  exposes  the  anterior  surface  of  the  right 
kidney.  Into  the  opening  thus  made  the  finger  is  introduced  and 
the  second  part  of  the  duodenum,  together  with  the  head  of  the 


534 


ABDOMEN  AND  BACK. 


pancreas,  separated  and  lifted  aAvay  from  the  posterioi  wall  of  the 
abdomen  up  into  the  abdominal  incision  and  steadied  there  during 
the  succeeding  steps  of  the  operation.     The  impacted  stone  within 


Fig.  239. — Lower  Part  of  Common  Duct.  Portion  of  the  wall  of  the 
duodenum  removed  to  show  the  point  where  the  common  duct  opens  into 
the  duodenum.  1.  Ampulla  of  Vater.  2.  Intramural  portion  of  common  duct. 
3.  Portion  of  duct  just  above  the  intramural  portion.    P,  Pancreatic  duct. 

the  common  duct  can  he  felt  through  the  wall  of  the  duodenum 
and  may  be  fixed  between  the  fingers  that  support  the  duodenum. 
The  gauze  pads  are  arranged  to  protect  the  adjacent  peritoneal 
surfaces  and  the  duodenum  incised,  making  an  opening  either  longi- 
tudinal or  transverse  in  direction,  and  from  one  to  one  and  one- 


OPERATIONS  UPON  THE  GALL-DUCTS.  525 

half  inches  long.  IMaterial  from  the  incised  duodeninn  is  wiped 
away  as  fast  as  it  escapes. 

The  calculus  may  be  impacted  in  the  am])ulla  of  Vater,  the 
dilated  portion  of  the  duet  immediately  above  the  orilice,  and  may 
be  seen  presenting  into  the  intestine  through  the  orifice;  or  it  may 
be  impacted  higher  up,  just  above  the  ampulla  of  Vater,  in  the 
Intramural  portion  of  the  duet.  The  stone  is  extracted  with  the 
forceps  through  the  orifice.  It  may  be  necessary  to  stretch  or 
incise  the  orifice  before  this  can  be  done.  The  orifice  of  the  duct 
is  incised  by  snipping  with  the  scissors  in  an  upward  direction.  If 
the  stone  is  impacted  above  the  ampulla  of  Vater,  in  the  intra- 
mural portion  of  the  duct,  it  may  be  necessary  to  extend  the  inci- 
sion from  the  orifice,  upward,  for  a  distance  of  one-half  to  three- 
quarters  of  an  inch  before  the  stone  can  be  extracted. 

Occasionally  the  stone  is  impacted  still  higher  vip  in  the  duct 
(above  the  intramural  portion  of  the  duct),  and  cannot  be  seized  and 
delivered  through  the  orifice.  Under  these  circumstances  it  becomes 
necessary  to  cut  down  upon  the  stone  in  order  to  remove  it.  This 
incision  goes  through  the  entire  thickness  of  the  wall  of  the  duo- 
denum and  through  the  wall  of  the  common  duct.  The  contiguous 
edges  of  the  opening  which  is  thus  made  from  the  duodenum  into 
the  common  duct  are  sewed  to  each  other  with  several  interrupted 
sutures  of  fine  chromic  catgut  and  thus  there  is  established  a  fistu- 
lous communication  between  the  common  duct  and  duodenum 
(Choledoclio-duodenostomy  Interna).  Owing  to  the  inflammatory 
process  that  accompanies  stone  impaction  of  the  common  duct  the 
adjoining  walls  of  the  common  duct  and  duodenum  are  usually 
found  already  adherent  to  each  other,  so  that  the  stitches  might 
safely  be  omitted.  It  is  better,  however,  to  suture  the  edges  as 
described. 

After  the  stone  has  been  removed  a  thick  probe  on  the  finger 
is  introduced  through  the  orifice  or  incision  into  the  duct  and  search 
made  for  additional  calculi. 

The  incision  in  the  duodenum  is  closed  with  a  non-penetrating 
Lembert  suture  of  silk.  The  incision  in  the  abdomen  is  closed  layer 
by  layer  as  in  the  operations  described  above  unless  the  common 
duct  or  the  gall-bladder  is  drained  (see  "Supraduodenal  Chole- 
doehotomy"). 


526 


ABDOMEN  AND  BACK. 


THE  PANCREAS. 

Surgical  Anatomy  of  the  Pancreas. — ^The  pancreas  is  an  elongated 
glandular  organ  from  six  to  eight  inches  long,  its  hreadth  equal  to 
about  one-fourth  its  length;  it  is  about  one-half  inch  in  thickness 


Fig.  240. — Pancreatic  duct  opens  through  a  separate  orifice  upon  the  summit  of 
the  papilla  into  the  duodenum.    C,  Common  duct;  P,  Pancreatic  duct. 

from  before  backward.  It  is  placed  transversely  in  the  upper  back 
part  of  the  abdominal  cavity,  lying  behind  the  stomach  across  the 
body  of  the  second  lumbar  vertebra.  It  consists  of  a  head,  body  and 
tail,  the  tail  abutting  against  the  spleen. 


SURGICAL  ANATOMY  OF  THE  PANCREAS.  527 

The  head  lies  to  the  right  of  the  vertehral  column,  resting  upon 
the  inferior  vena  cava,  right  crus  of  the  diaphragm  and  right  renal 
vessels  and  separated  from  the  inner  border  of  the  right  kidney  by 
the  second  part  of  the  duodenum.  The  common  bile-duct  is  located 
between  the  second  part  of  the  duodenum  and  the  head  of  the  pan- 
creas more  or  less  completely  surrounded  by  pancreatic  tissue. 

The  body  of  the  pancreas  lies  opposite  the  second  lumbar  vertebra 
upon  the  crus  (left)  of  the  diaphragm,  aorta,  thoracic  duct,  etc.  To 
the  left  of  the  vertebral  column  it  is  in  relation  with  the  renal  vessels 
and  left  kidney.  In  front  of  the  pancreas  are  the  peritoneum, 
stomach  and  transverse  colon.  The  splenic  artery  and  vein  run  along 
its  upper  border.  Its  lower  border  is  in  relation  with  the  third  part 
of  the  duodenum,  and  passing  forward  between  this  part  of  the  duo- 
denum and  the  lower  border  of  the  pancreas  are  the  superior  mesen- 
teric artery  and  vein. 

The  tail  of  the  pancreas  projects  to  the  left  as  far  as  the  spleen, 
to  which  it  is  connected  by  a  fold  of  peritoneum,  ligamentum  pan- 
creatico-lienale. 

The  pancreas  is  covered  by  the  peritoneum  upon  its  anterior  sur- 
face only.  The  transverse  mesocolon  passes  backward,  and  upon  reach- 
ing the  pancreas  its  layers  separate;  the  upper  layer  passes  upward, 
covering  the  front  surface  of  the  pancreas,  and  lines  the  back  wall 
of  the  upper  part  of  the  abdomen  (lesser  peritoneal  sac). 

The  pancreatic  duct,  duct  of  Wirsung,  courses  through  the  entire 
length  of  the  organ  from  left  to  right  and  empties  into  the  second 
part  of  the  duodenum.  The  duct  penetrates  the  inner  wall  of  the 
duodenum  very  obliquely  and  in  close  relationship  with  the  common 
bile-duct  and  usually  terminates  by  opening  into  the  lower  dilated 
part  of  the  common  bile-duct :  the  ampulla  of  Yater.  The  orifice 
of  the  common  duct  is  marked  by  a  papilla  which  is  situated  upon 
the  inner  wall  of  the  second  part  of  the  duodenum  from  three  to  four 
inches  below  the  pylorus.  In  some  cases  the  pancreatic  duct  does  not 
terminate  in  the  ampulla  of  Yater,  but  opens  into  the  duodenum 
independently  of  the  common  bile-duct  through  a  separate  orifice  upon 
the  summit  of  the  papilla. 

A  calculus  lodged  in  the  ampulla  of  Yater  may  compress  the 
end  of  the  pancreatic  duct  and  cause  obstruction  to  the  escape  of  the 
pancreatic  juice  into  the  duodenum  or,  as  pointed  out  by  Opie,  in 
those  cases  where  the  pancreatic  duct  opens  into  the  ampulla  of  Yater 
a  small  stone  obstructing  the  duodenal  orifice  of  the  ampulla  of  Yater 
might  serve  to  divert  the  stream  of  infected  bile  from  the  common 


528  ABDOMEN  AND  BACK. 

bile-duct  into  the  iDancreatic  duct  (see  Fig.  239)  and  thus  lead  to  seri- 
ous disease  of  the  pancreas — hemorrhagic  pancreatitis  and  gangrene. 

In  addition  to  the  pancreatic  duct  already  described,  that  of  Wir- 
sung,  there  is  a  second  one  normally  present,  the  duct  of  Santorini. 
The  orifice  of  the  duct  of  Santorini  can  usually  be  demonstrated  upon 
the  inner  wall  of  the  duodenum  about  one  inch  nearer  the  pylorus  than 
the  papilla  that  marks  the  opening  of  the  common  bile-duct  and  duct 
of  Wirsung.  AVithin  the  pancreas  the  duet  of  Santorini  usually 
anastomoses  with  the  duct  of  Wirsung.  In  some  exceptional  cases  the 
duct  of  Santorini  is  larger  than  the  duct  of  Wirsung  and  may  func- 
tionate for  the  latter. 

The  induration  that  results  from  chronic  inflammatory  processes 
that  involve  the  head  of  the  pancreas  and  which  are  frequently  asso- 
ciated with  cholelithiasis  and  the  passage  of  gall-stones  through  the 
common  bile-duct,  may  cause  symptoms  of  obstructive  jaundice  by 
compression  of  the  common  duct;  malignant  growths  involving  the 
head  of  the  pancreas  may  have  a  similar  effect  upon  the  common  duct. 

OPERATIONS  UPON  THE  PANCREAS. 

The  operative  treatment  of  diseases  of  the  pancreas  forms  a  com- 
paratively new  chapter  in  surgery.  As  the  functions  of  the  organ  and 
the  pathological  processes  that  affect  it  become  better  understood  the 
results  of  surgical  interference  become  more  satisfactory. 

Operative  procedures  are  undertaken  for  the  purpose  of  treating 
injuries,  inflammatory  conditions,  and  new  growths  in  the  shape  of 
cysts  and  solid  tumors. 

Fat  IsTeceosis. — Injuries  and  inflammatory  conditions  that  are 
accompanied  by  a  destruction  of  the  tissue  of  the  pancreas  are  very 
likely  to  be  complicated  by  necrosis  of  the  fatty  tissue  in  and  about 
the  pancreas  and  in  the  mesentery,  omentum,  subperitoneal  connective 
tissue,  etc.  This  phenomenon  of  fat  necrosis  is  caused  by  the  direct 
action  of  the  pancreatic  secretion  that  escapes  from  the  injured  gland. 
Langerhans  and  Flexner  have  demonstrated  a  ferment  in  the  pan- 
creatic juice  which  is  capable  of  reducing  the  living  fat  into  its  fatty 
acid  and  glycerin,  and  this  is,  no  doubt,  the  active  agent  in  producing 
the  peculiar  condition  of  fat  necrosis.  After  the  fat  has  been  split 
up  in  this  manner  the  glycerin  is  absorbed  and  the  fatty  acid  remain- 
ing combines  with  lime  salts  and  thus  there  are  produced  little,  opaque 
areas  of  a  dull  white  or  yellow  color  in  place  of  the  fatty  tissue  that 
has  been  broken  up.  When  the  abdomen  is  opened  the  omentum,  etc., 
are  found  studded  with  these  areas.     These  spots  are  flat,  and  vary  in 


OPERATIONS  UPON  THE  PANCREAS.  529 

size  from  a  pin-liead  to  a  pea  or  larger  and  stand  out  in  marked  con- 
trast to  the  bright,  glistening  yellow  of  the  normal  fat.  Recognition 
of  this  condition  of  fat  necrosis  during  tlie  course  of  operation  is  of 
the  greatest  significance  to  the  surgeon  and  should  direct  his  atten- 
tion at  once  to  the  pancreas  as  the  seat  of  grave  disease  or  injury. 

Incisioxs  to  Obtain  Access  to  the  Pancreas. — The  pancreas 
is  situated  very  deep  in  the  upper  back  part  of  the  abdomen.  It  is 
usually  approached  from  in  front,  the  incision  being  placed  above  the 
uml^ilicus  in  the  middle  line  or  to  one  or  the  other  side  of  the  middle 
line,  penetrating  between  the  fibers  of  the  rectus  muscle.  After  the 
abdomen  has  been  opened,  it  will  be  necessary,  in  order  to  reach  the 
pancreas,  to  enter  the  lesser  peritoneal  sac.  This  may  be  accomplished 
through  an  opening  which  is  made  for  the  purpose  in  the  lesser  omen- 
tum, gastro-hepatic  ligament,  or  through  an  opening  corresponding 
to  the  lower  border  of  the  stomach  which  is  made  in  the  gastro-colic 
ligament.  Access  to  the  pancreas  may  also  be  gained  through  a  rent 
torn  in  the  transverse  mesocolon ;  the  transverse  colon  and  the  great 
omentum  are  reflected  upward  and  the  mesocolon  penetrated  from 
below  bluntly  in  order  to  avoid  injury  of  the  arteria  colica  media. 
The  head  of  the  pancreas  may  be  exposed  by  penetrating  between  the 
duodenum  and  pancreas  after  the  peritoneum  which  is  reflected  over 
its  anterior  surface  has  been  incised. 

The  pancreas  has  also  been  exposed  through  an  oblique  incision 
commencing  near  the  tip  of  the  twelfth  rib  and  passing  forward  toward 
the  umbilicus;  or  beginning  below  the  tip  of  the  twelfth  rib  the 
incision  may  be  carried  forward,  running  below  and  parallel  with  the 
free  border  of  the  costal  cartilages. 

By  a  Retroperitoneal  Method. — The  pancreas  may  be  approached 
through  an  incision  in  the  lumbar  region.  The  incision  is  placed 
along  the  outer  border  of  the  erector  spinas  muscle  commencing  at 
the  twelfth  rib  and  carried  downward  or  downward  and  outward. 
This  route  may  be  employed  for  the  purpose  of  evacuating  cysts, 
abscesses,  etc.,  if  the  head  or  tail  of  the  organ  is  the  part  chiefly 
affected  and  if  the  tumor  occupies  a  position  well  to  one  side  or  the 
other  of  the  middle  line.  A  cyst,  etc.,  under  favorable  conditions, 
may  be  thus  emptied  without  entering  the  peritoneal  cavity. 

Drainage  should  be  provided  in  all  operations  where  the  pancreas 
is  found  injured  or  diseased  so  as  to  prevent  as  far  as  possible  the 
entrance  into  the  peritoneal  cavity  of  pancreatic  juice,  etc.,  in  the 
event  of  leakage. 

For  Injuries. — Owing  to  its  protected  position,  the  pancreas  is 

34 


530  ABDOMEN  AND  BACK. 

seldom  the  seat  of  injurjr  without  adjacent  important  organs  being 
seriously  involved.  In  stab  and  gunshot  wounds  of  the  stomach  the 
pancreas  is  frequently  found  injured  as  well.  In  severe  non-pene- 
trating traumatisms  of  the  abdomen,  run-over,  kicks,  etc.,  where  the 
pancreas  is  injured,  the  intestine,  duodenum,  is  likely  to  be  ruptured. 
In  operations  for  wounds  of  the  abdominal  viscera,  especially  if  the 
stomach  or  duodenum  is  involved,  the  condition  of  the  pancreas  should 
always  be  carefully  investigated.  The  pancreas  may  be  reached  by 
entering  the  lesser  peritoneal  cavity  through  an  opening  which  is 
made  for  the  jDurpose  in  the  gastro-colic  ligament.  This  is  detached 
for  a  sufficient  extent  from  the  lower  border  of  the  stomach. 

Wounds  of  the  pancreas  are  to  be  closed  with  deep  and  superficial 
sutures  of  catgut  in  order  to  control  the  hemorrhage  and  to  prevent 
as  far  as  possible  the  leakage  of  pancreatic  secretion  into  the  peri- 
toneal cavity.  The  presence  of  this  material  in  the  peritoneal  cavity 
is  capable  of  setting  up  a  fatal  peritonitis  and  is  the  cause  of 
the  fat  necrosis.  Owing  to  the  friable  nature  of  the  pancreatic 
tissue,  difficulty  may  be  experienced  in  getting  the  sutures  to  hold. 
If  the  tail  of  the  pancreas  is  the  part  involved  the  injured  portion  may 
be  tied  off  and  excised.  Proper  drainage  should  be  provided  in  all  of 
these  cases.  A  plug  of  strip  gauze  is  introduced  through  the  open- 
ing in  the  gastro-colic  ligament  down  to  the  site  of  the  wound  in 
the  pancreas,  its  free  end  emerging  through  the  abdominal  incision 
near  the  umbilicus. 

Xeedless  to  say,  accompanying  wounds  of  the  stomach,  intestine, 
spleen,  kidneys,  etc.,  should  be  properly  disposed  of.  The  abdomen 
is  wiped  dry  and  the  incision  closed  for  part  of  its  length. 

For  Cysts. — The  exact  nature  of  the  origin  of  all  pancreatic  cysts 
is  not  known.  A  considerable  number  are,  no  doubt,  caused  by 
occlusion  of  the  larger  or  smaller  ducts  by  calculi  or  they  may  be 
caused  by  stenosis  of  the  smaller  ducts  due  to  chronic  inflammatory 
processes  seated  in  the  pancreas  itself  or  extending  from  adjacent 
organs.  The  cysts  usually  first  make  their  presence  known  in  the 
shape  of  a  palpable  tumor  occupying,  as  a  rule,  the  upper  part  of 
the  abdominal  cavity. 

The  abdominal  incision  is  placed  above  the  umbilicus,  in  the 
linea  alba  or  to  one  or  the  other  side  of  the  middle  line.  When  the 
abdomen  is  opened  the  cyst  may  be  found  presenting  forward 
through  the  gastro-hepatic  ligament,  above  the  stomach,  pushing  the 
stomach  down  or  else — and  this  is  more  common — it  ma}'^  present 
below  the  stomach,  between  it  and  the  transverse  colon,  forcing  the 


OPERATIONS  UPON  THE  PANCREAS.  531 

stomach  upward  toward  the  liver  and  the  transverse  colon  down- 
ward. In  still  other  cases  the  cyst  may  dissect  its  way  forward 
between  the  layers  of  the  transverse  mesocolon  pushing  the  trans- 
verse colon  in  front  of  it  or  it  may  grow  downward  and  forward 
so  as  to  present  below  the  transverse  colon. 

The  cyst  may  be  emptied  and  drained  or  an  attempt  may  be 
made  to  extirpate  it. 

Evacuation  and  Drainage. — After  the  cyst  has  been  exposed  its 
contents  are  evacuated  as  nearly  completely  as  possil)le  with  the 
trochar,  and  then  it  is  incised.  The  edges  of  the  incision  are 
sutured  to  the  peritoneum  and  deep  muscle  in  the  abdominal  inci- 
sion. The  abdominal  incision  is  closed  for  part  of  its  extent  with 
interrupted  silk  sutures  and  a  large  drainage  tube  surrounded  with 
strip  gauze  is  introduced  down  into  the  bottom  of  the  cyst. 

Without  preliminary  evacuation,  the  cyst  may  be  fixed  to  the 
edges  of  the  abdominal  incision  and  opened  later,  after  adliesions 
have  had  time  to  form. 

If  the  cyst  is  small  and  cannot  be  brought  up  into  the  abdominal 
incision  a  purse-string  suture  may  be  applied  about  the  margin  of 
the  opening  in  the  cyst  and  a  large  rubber  tube  introduced.  The 
purse-string  is  drawn  tight,  thus  closing  the  edges  of  the  opening 
securely  about  the  tube.  The  tiibe  may  be  fixed  to  the  margin  of 
the  incision  in  the  cyst 'with  a  catgut  suture  in  order  to  make  certain 
that  it  will  not  become  displaced.  Strip  gauze  is  ^oacked  around  the 
drainage  tube  down  to  the  site  of  the  incision  in  the  cyst.  The 
alidominal  incision  is  closed  for  part  of  its  extent  with  interrupted 
silk  sutures. 

An  additional  counter-opening  with  the  object  of  providing  still 
better  drainage  may  be  made  in  the  lumbar  region,  or  after  the  diag- 
nosis has  been  made  the  anterior  abdominal  incision  may  be  closed 
and  the  cyst  drained  exclusively  through  a  lumbar  incision. 

In  some  cases  following  this  plan  of  treatment  a  fistula  persists 
for  a  long  time,  but,  as  a  rule,  it  closes  ultimately. 

Extirpation. — Extirpation  of  a  pancreatic  cyst  either  partial  or 
complete  is  seldom  advisable.  The  adhesions  are  frequently  found 
to  be  very  extensive  and  firm  and  under  such  conditions  extirpation 
would  be  difficult  and  dangerous. 

In  some  cases  the  adhesions  are  of  such  a  character  that  the 
tumor  can  be  isolated  by  blunt  dissection,  working  with  the  fingers 
very  close  to  the  wall  of  the  cyst  and  occasionally  doubly  ligating 
and  dividing  bands  of  adhesions.     After  the  cyst  has  been  entirely 


532  ABDOMEN  AND  BACK. 

separated  the  pedicle  that  joins  the  cyst  to  the  pancreas  mnst  be 
secured.  This  is  Hgatured  and  clamped  before  it  is  divided  in 
removing  the  cyst.    In  these  cases  also  drainage  should  be  provided. 

The  abdominal  incision  is  closed  in  part. 

For  Acute  Pancreatitis. — The  process  which  has  been  described 
as  acute  hemorrhagic  pancreatitis  is  probably  caused  by  a  retrograde 
infection  extending  along  the  pancreatic  duct  either  from  the  duo- 
denum or  common  bile-duct.  Opie  says  that  a  small  calculus  block- 
ing the  duodenal  orifice  of  the  ampulla  of  Vater  in  those  cases  where 
the  pancreatic  duct  opens  into  the  ampulla,  and  not  independently 
upon  the  wall  of  the  duodenum,  may  cause  the  stream  of  infected 
bile  to  be  diverted  into  the  pancreatic  duct  and  thus  set  up  just  such 
an  infectious  inflammatory  process.  The  condition  is  accompanied 
by  destruction  of  pancreatic  tissue,  and  as  a  result  the  pancreatic 
juice  is  able  to  escape  into  the  substance  of  the  pancreas  and  into 
the  peritoneal  cavity,  producing  the  peculiar  phenomena  of  necrosis 
of  the  fatty  tissue  with  which  it  comes  in  contact  in  and  about  the 
pancreas  and  in  the  omentum,  mesenter}^,  subperitoneal  connective 
tissue,  etc.  This  secretion  also  carries  septic  agents  to  the  peritoneal 
cavity  and  is  capable  of  setting  up  a  peritonitis  which  is  fatal  unless 
it  can  be  controlled  by  the  surgeon.  The  diagnosis  in  these  cases  is 
usually  not  made  until  after  the  abdomen  has  been  opened. 

The  incision  is  best  placed  in  the  middle  line  above  the  um- 
bilicus. When  the  abdomen  is  opened  the  peritoneal  cavity  is 
usually  found  containing  blood-stained,  purulent  fluid  and  the 
omentum,  etc.,  marked  by  small  patches  of  fat  necrosis  varying  in 
size  from  a  pin-head  to  a  pea  or  larger.  These  appearances  are  of 
peculiar  significance  and  should  direct  the  attention  of  the  operator 
at  once  to  the  pancreas.  After  the  abdominal  cavity  has  been  wiped 
dry  the  lesser  peritoneal  cavity  should  be  entered.  An  incision  is 
made  for  this  purpose  in  the  gastro-colic  ligament.  Occasionally, 
and  especially  if  the  condition  has  existed  for  a  longer  time,  the 
foramen  of  Winslow  will  have  become  occluded  and  the  lesser  peri- 
toneal sac  will  be  found  converted  into  a  large  abscess  cavity  filled 
with  blood}'',  purulent  fluid. 

Instead  of  proceeding  as  indicated  above,  the  medium  explora- 
tory incision  may  be  closed  and  the  abscess  cavity  opened  and 
drained  through  an  incision  in  the  left  lumbar  region;  or  through 
an  incision  that  commences  in  the  left  Imnbar  region  near  the  tip 
of  the  twelfth  rib  and  which  is  carried  forward  parallel  Avith  and  a 
short  distance  away  from  the  free  border  of  the  ribs. 


SURGICAL  ANATOMY  OF  THE  SPLEEN.  533 

In  all  cases  after  evacuating  the  abscess  and  wiping  the  cavity 
dry.  drainage  should  be  provided  in  the  shape  of  a  plug  of  strip  gauze. 

The  incision  is  closed  for  part  of  its  extent. 

For  Tumors. — Xew  growths  affecting  the  pancreas  primarily  are 
comparatively  rare.  Carcinoma,  adenoma,  and  sarcoma  have  been 
described.  Carcinoma  usually  affects  the  head  of  the  organ  and 
may  cause  obstructive  jaundice  by  compressing  the  common  bile- 
duct.  Tumors  involving  the  tail  of  the  pancreas  may  be  treated  by 
resection  of  the  affected  portion  of  the  organ.  Diseased  portions  of 
the  pancreas  have  been  resected  during  the  course  of  operations 
upon  the  stomach. 

The  abdomen  is  opened  through  an  incision  in  the  middle  line 
and  the  pancreas  reached  through  an  opening  in  the  gastro-hepatic 
or  gastro-colic  ligament  or  transverse  mesocolon.  Drainage  should 
be  provided  in  all  these  cases. 

THE    SPLEEN. 

The  Surgical  Anatomy  of  the  Spleen. — The  spleen  is  a  solid  organ 
located  in  the  upper  left  part  of  the  abdomen  in  close  relation  with 
the  fundus  of  the  stomach,  to  which  it  is  attached  by  the  gastro- 
splenic  ligament  (omentum),  being  suspended  from  the  diaphragm 
by  the  phrenico-splenic  ligament,  its  lower  end  resting  upon  the 
phrenico-colic  ligament.  The  spleen  is  rather  ellipsoidal,  although 
its  shape  may  vary.  It  measures  usually  about  12  cm.  in  its  long 
diameter,  8  cm.  in  breadth,  and  3  cm.  in  thickness.  Its  size  may 
vary  considerably. 

Its  outer  surface  is  smooth  and  rounded,  and  looks  outward, 
upward,  and  backward  toward  the  diaphragm,  which  separates  it 
from  the  pleura  and  the  edge  of  the  lung  and  the  ninth,  tenth,  and 
eleventh  ribs.  Its  inner  surface  consists  of  two  areas:  the  anterior, 
the  gastric  surface,  which  is  the  broader,  looks  inward  and  forward, 
and  lies  close  to  the  posterior  surface  of  the  fundus  of  the  stomach ; 
the  posterior  portion  of  the  inner  surface  is  in  contact  with  the 
upper  and  outer  part  of  the  left  kidney  and  the  tail  of  the  pancreas. 
Between  these  two  areas  the  inner  surface  presents  the  hilum, 
where  the  vessels  and  nerves  pass  in  and  out  of  the  organ. 

The  lower  end  of  the  spleen  is  in  relation  with  the  splenic  flex- 
ure of  the  colon,  and  rests  upon  the  phrenico-colic  ligament,  which 
supports  it.  The  anterior  border  is  rather  sharp,  and  marked  by  a 
varying  number  of  notches,  usually  one.  Oftentimes  when  the  organ 
is  enlarged  the  anterior  notched  edge  can  be  made  out  by  palpation 


534  ABDOMEN  AND  BACK. 

through  the  abdominal  wall.  The  posterior  border  is  rounded  and 
thick. 

The  splenic  artery  is  a  branch  of  the  coeliac  axis,  and  in  its 
course  to  the  hiluni  of  the  spleen  runs  along  the  upper  border  of  the 
pancreas,  lying  above  the  splenic  vein.  The  splenic  vein  is  as  large 
around  as  one's  finger — twice  as  large  as  the  splenic  arter}^.  It 
emerges  in  several  branches  from  the  hilum  of  the  spleen,  runs  along 
the  upper  border  of  the  pancreas,  and  after  receiving  the  inferior 
mesenteric  vein  joins  with  the  superior  mesenteric  to  form  the  portal 
vein. 

The  spleen  is  almost  completely  invested  by  the  peritoneum, 
which  is  intimately  blended  with  the  firm  capsule  proper  of  the 
organ.  The  spleen  is  fixed  to  the  stomach  by  the  gastro-splenic 
ligament  (omentum)  and  to  the  diaphragm  by  the  phrenico-splenic 
ligament,  the  suspensory  ligament.  Its  lower  end  rests  upon  the 
phrenico-colic  ligament. 

The  gastro-splenic  ligament,  or  omentum,  is  the  fold  of  peri- 
toneum which  is  reflected  from  the  fundus  of  the  stomach  over  to 
the  spleen,  and  between  its  layers  the  splenic  vessels  pass  to  and 
from  the  hilum  of  the  spleen  and  the  vasa  brevia  to  the  fundus  of 
the  stomach.  The  phrenico-splenic  ligament,  or  suspensory  liga- 
ment, is  the  fold  of  peritoneum  which  is  reflected  from  the  dia- 
phragm to  the  s])leen. 

OPERATIONS  UPON  THE  SPLEEN. 

Splenotomy. — Incision  of  the  spleen  for  the  purpose  of  evacu- 
ating and  draining  an  abscess  or  an  hydatid  cyst. 

The  abdominal  incision  may  vary  according  to  the  location  of 
the  tumor,  if  one  can  be  made  out.  A  vertical  incision  through  the 
middle  or  outer  part  of  the  left  rectus  muscle  and  extending  from 
the  costal  cartilages  downward  for  a  distance  of  four  or  five  inches 
may  be  employed;  or  an  oblique  incision  below  and  parallel  with 
the  left  costal  arch  may  be  made.  The  operation  may  be  performed 
in  one  or  two  sittings. 

Ik  One  Sitting. — After  the  spleen  has  been  exposed,  if  it  is 
found  adherent  to  the  parietal  peritoneum  it  may  be  incised  at  once 
and  packed  with  strip  gauze.  If  the  spleen  is  not  adherent  to  the 
abdominal  parietes  it  should  be  drawn  into  the  incision  and  steadied 
there  while  gauze  pads  are  packed  into  the  incision  and  about  the 
spleen  to  protect  the  peritoneal  cavity  from  soiling.  Fluid  under 
tension  should  be  drawn  off  as  nearly  completely  as  possible  with  the 


OPERATIONS  UPON  THE  SPLEEN.  535 

aspirator  so  as  to  avoid  flooding  when  the  organ  is  incised.  The 
spleen  is  freely  incised  and  the  edges  of  the  opening  thus  made  are 
sutured  to  the  edges  of  the  abdominal  incision.  The  abscess  or  cyst 
cavity  is  packed  with  strip  gauze  and  the  abdominal  incision  closed  in 
part. 

]x  Two  Sittings. — After  the  spleen  has  been  exposed  as  described 
above  it  is  fixed  to  the  edges  of  the  abdominal  incision  with  several 
catgut  sutures.  Each  suture  pierces  the  capsule  and  the  substance  of 
the  spleen  superficially  and  includes  the  parietal  peritoneum,  fascia 
transversal  is  and  deep  muscle  layers  in  the  abdominal  incision.  Strip 
gauze  is  packed  through  the  incision  down  to  the  surface  of  the  spleen 
and  the  abdominal  incision  closed  in  part.  It  is  not  necessary  in  all 
cases  to  suture  the  exposed  spleen  to  the  edges  of  the  abdominal 
incision.  It  suffices  for  the  purpose  of  inducing  adhesion  between,  the 
spleen  and  abdominal  wall  to  pack  strip  gauze  down  through  the 
incision  to  the  spleen. 

After  the  lapse  of  two  or  three  days,  adhesions  having  formed 
between  the  exposed  surface  of  the  spleen  and  the  abdominal  wall, 
the  abscess  or  cyst  may  be  incised  and  drained. 

Splenorrhaphy. — Suturing  of  wounds,  lacerations,  of  the  spleen 
for  the  purpose  of  controlling  hemorrhage.  Sutures  of  catgut  are  used 
and  should  take  a  broad  deep  bite.  They  tear  through  if  much  tension 
is  made.  Hemorrhage  from  the  spleen  may  be  controlled  by  methods 
similar  to  those  described  for  control  of  hemorrhage  from  the  liver. 
It  would  probably  be  well  in  some  cases  of  hemorrhage  to  extirpate  the 
spleen. 

Splenopexy. — Fixation  of,  or  anchoring,  the  spleen.  This  opera- 
tion is  performed  for  "wandering"  or  "floating"  spleen.  If  the 
"floating"  spleen  is  more  than  twice  the  normal  size  or  if  diseased  it 
should  be  extirpated  rather  than  anchored.  One  method  of  fixation 
has  been  described  by  Eydygier  and  another  by  Bardenheuer. 

Etdygier''s  Method.  —  The  abdomen  is  opened  through  an 
incision  in  the  middle  line,  commencing  near  the  ensiform  cartilage 
and  reaching  to  or  beyond  the  umbilicus ;  or  an  incision  may  be  made 
through  the  middle  of  the  left  rectus  muscle.  Corresponding  as 
nearly  as  possible  to  the  normal  position  of  the  spleen,  ninth  to  eleventh 
ribs,  a  pocket  is  formed  in  the  parietal  peritoneum  by  making  a 
transverse,  slightly  curved  incision  with  the  convexity  upward  in  the 
parietal  peritoneum  and  then  tearing  the  peritoneum  loose  from  the 
abdominal  wall  to  an  extent  sufficient  to  make  a  pouch  that  will 
accommodate  the  lower  half  of  the  spleen.     The  spleen  is  placed  in 


536  ABDOMEN  AND  BACK. 

the  pouch  thus  formed  and  secured  there  by  several  interrupted  sutures 
that  unite  the  free  edge  of  the  peritoneal  pouch  to  the  gastro-splenic 
omentum.  In  order  to  prevent  further  separation  of  the  peritoneum 
and  the  spleen  from  sinking  farther  into  the  peritoneal  pouch  one  or 
two  silk  sutures  are  introduced  through  the  parietal  peritoneum  and 
the  deep  abdominal  muscles.  These  sutures  are  applied  from  within 
the  abdomen  and  are  placed  just  below  the  bottom  of  the  peritoneal 
pocket.  The  free,  serous  surface  of  the  spleen  and  opposite  parietal 
peritoneum  may  be  vigorously  rubbed  with  a  gauze  wipe  to  induce  addi- 
tional adhesions.     The  abdomen  is  closed  without  drainage. 

Bardenheuer''s  Method. — The  incision  commences  near  the  iliac 
crest  and  extends  upward  in  the  mid-axillary  line  almost  as  far  as  the 
tenth  rib — about  10  cm.  long.  From  the  upper  end  of  this  incision 
a  second  one  is  made,  about  the  same  length,  extending  backward 
along  the  lower  border  of  the  tenth  rib.  The  incision  penetrates  all 
the  layers  of  the  abdominal  wall  down  to,  but  not  through,  the  parietal 
peritoneum.  The  angular  flap  thus  outlined  is  reflected  downward 
and  the  parietal  peritoneum,  unopened,  is  exposed.  A  small  incision 
is  made  in  the  peritoneal  layer  and  the  spleen  secured  and  drawn  out 
through  it  edgewise  and  the  edges  of  the  opening  in  the  peritoneum 
fixed  all  around  to  the  pedicle  of  the  spleen,  gastro-splenic  omentum, 
with  interrupted  sutures  of  silk.  A  silk  throad  is  then  passed  over  the 
tenth  rib  and  through  the  lower  pole  of  the  -spleen,  but  this  is  not 
tied  until  later.  Corresponding  to  the  lower  end  of  the  spleen  several 
silk  sutures  are  introduced  joining  the  deep  fascia  of  the  reflected 
abdominal  flap  to  the  su:bperitoneal  connective  tissue  in  order  to  pre- 
vent the  spleen,  later,  from  sinking  further  downward  between  the 
peritoneum  and  abdominal  wall.  The  suspensory  suture  which  was 
thrown  over  the  tenth  rib  is  then  tied. 

The  abdominal  flap  is  replaced  and  sutured  accurately  layer  by 
layer  with  catgut.  The  suture  may  be  reinforced  with  a  number  of 
interrupted  silk  sutures  that  penetrate  through  the  skin,  fascia,  and 
divided  muscle. 

Splenectomy. — Extirpation  of  the  spleen. 

The  operation  is  done  for  wounds,  rupture,  prolapse;  tumors — 
cystic,  hydatid,  and  solid,  sarcoma;  wandering  spleen  if  much 
enlarged  or  diseased;   idiopathic  h3^pertrophy ;   primary  tuberculosis. 

Incision  must  be  sufficiently   large.     It  may  be   placed  in  the* 
middle  line,  reaching  from  near  the  ensiform  process  downward  to  or 
beyond  the  umbilicus.     As  a  rule,  better  access  is  had  through  an 
incision    penetrating    through    the    left    rectus    muscle.     It    may   be 


OPERATIONS  UPON  THE  SPINAL  COLUMN.  537 

necessary,  if  the  spleen  is  very  large,  to  make  an  additional  transverse 
cut  outward  toward  the  flank  or  inward  through  the  body  of  the  left 
rectus  muscle  toward  the  middle  line.  Some  surgeons  advise  an 
oblique  incision  passing  downward  and  backward  below  and  parallel 
with  the  left  costal  arch. 

After  the  abdomen  has  been  opened  the  spleen  is  sought  for  and 
recognized.  If  adhesions  are  present  these  are  broken  up  bluntly  with 
the  fingers  or  if  they  are  thick  and  vascular  they  may  be  ligated  doubly 
and  cut.  In  freeing  the  spleen  the  operator  must  avoid  injuring  its 
capsule,  otherwise  there  may  be  much  troublesome  hemorrhage. 

After  the  spleen  has  been  separated  from  adhesions  it  is  drawn 
well  forward  into  the  incision.  This  efi:ort  is  resisted  by  the  normal 
peritoneal  folds  that  connect  the  spleen  with  the  stomach,  gastro- 
splenic  omentum,  and,  with  the  diaphragm,  phrenico-splenic  ligament. 
The  pedicle  of  the  spleen,  which  consists  practically  of  the  gastro- 
splenic  omentum  (including  the  splenic  vessels),  may  be  transfixed, 
through  its  middle,  with  a  curved,  blunt-pointed  ligature  carrier,  pro- 
vided with  a  long  strand  of  strong,  plain  catgut.  After  this  ligature 
has  been  placed  it  is  cut  so  as  to  make  two,  and  these  are  then  tied,  one 
including  the  upper  half  of  the  pedicle  and  the  other  the  lower  half. 
The  tail  of  the  pancreas  should  not  be  included  in  tying  these  ligatures. 
If  the  phrenico-splenic  ligament  is  not  already  included  in  the  liga- 
tures placed  as  described,  this  structure  may  now  be  ligated  and  in 
a  similar  manner.  The  ligatures  are  tied  very  tight  and  left  long  to 
serve  as  tractors  in  order  to  pull  the  stump  of  the  pedicle  into  the 
wound  for  final  inspection  after  the  spleen  has  been  cut  away. 

The  pedicle  is  cut  close  to  the  spleen  and  the  organ  removed; 
the  stump  of  the  pedicle  may  be  drawn  gently  forward  and  an  effort 
made  to  isolate  and  ligate  the  splenic  artery  and  vein,  each  separately. 
If  the  pedicle  is  properly  secured  there  is  little  danger  of  subsequent 
hemorrhage.  After  the  spleen  has  been  removed  care  should  be  taken 
to  secure  any  remaining  bleeding  points. 

The  incision  in  the  abdomen  is  closed  without  drainage,  layer 
by  layer. 

OPERATIONS  UPON  THE  SPINAL  COLUMN. 

Laminectomy. — IJesection  of  the  laminae  of  the  vertebrae  for  the 
purpose  of  relieving  compression  of  the  cord  due  to  traumatism  or 
disease,  depressed  or  displaced  bone,  extravasated  blood,  pus,  tuber- 
culous products,  Pott's  disease,  tumors,  etc.  Tumors  may  grow  from 
the  vertebrse,  meninges,  or  cord  proper. 


538  ABDOMEN  AND  BACK. 

The  patient  is  placed  prone  upon  the  table  with  an  inflated  rubber 
cushion  under  the  ribs  to  give  the  back  a  slight  curve.  The  head 
should  be  upon  a  lower  level  than  the  part  of  the  back  which  repre- 
sents the  site  of  operation.  A  long  incision  is  madC;,  in  the  middle 
line,  through  the  soft  parts  down  to  the  tips  of  the  spinous  processes. 
The  middle  of  this  incision  should  correspond  to  the  probable  loca- 
tion of  the  injury  or  disease. 

The  soft  parts — muscles,  etc. — ^upon  either  side  of  the  middle 
line  are  then  freely  separated  with  a  periosteum  elevator  so  as  to 
expose  the  laminse  of  from  three  to  five  vertebrae. 

Hemorrhage  should  be  controlled,  oozing,  by  temporary  packing- 
with  a  hot  gauze  pad,  and  spurting  points  by  clamps  and  ligatures. 
The  spinous  processes  are  snipped  off  at  their  bases  with  the  cutting 
bone-forceps,  the  blades  of  which  may  be  conveniently  bent  at  an 
obtuse  angle. 

While  the  soft  parts,  detached  muscles,  etc.,  are  well  retracted, 
the  laminae,  if  not  already  fractured  by  a  traumatism,  are  divided 
and  then  removed. 

The  laminae  that  are  to  be  resected  should  first  be  stripped  bare 
of  their  periosteum  and  any  remaining  soft  parts  with  the  sharp- 
edged  periosteum  elevator,  and  then  divided  as  close  as  possible  ta 
the  transverse  processes,  first  on  one  side  and  then  on  the  other.  The 
division  of  the  laminae  may  be  accomplished  with  the  chisel  and  mal- 
let or  with  the  rongeur  forceps  or  with  the  cutting  bone-forceps.  The 
laminae  of  the  vertebra  which  corresponds  to  the  middle  of  the  wound 
are  resected  first  and  then  those  of  the  vertebrae  above  and  below.  The 
laminae  of  the  first  vertebra  attacked  may  be  divided  with  the  chisel 
and  mallet.  In  this  way  an  opening  is  made  into  the  spinal  canal 
and  through  it  the  laminae  above  and  below  can  be  readily  gouged 
away  with  the  rongeur  forceps. 

The  dura  mater  proper  may  be  exposed  by  tearing  with  a  blunt 
director  through  the  loose  connective  tissue  that  overlies  it.  In  thus 
exposing  the  dura  mater,  there  may  be  considerable  hemorrhage  from 
the  venous  plexus  that  is  located  in  the  posterior  part  of  the  vetebral 
canal  between  the  bony  wall  and  the  dura,  but  this  is  readily  controlled 
by  a  few  minutes'  compression  with  a  hot  gauze  pad.  After  the 
spinal  canal  has  been  opened  the  immediate  cause  of  the  symptoms 
may  present  itself  and  the  condition  may  be  remedied  without  open- 
ing the  dura;  for  example,  a  dislocated  vertebra,  tuberculous  granu- 
lation tissue,  extradural  tumor,  etc.     Prominent  angular  deformity  of 


OPERATIONS  UPON  THE  SPINAL  COLUMN. 


539 


Fig.  241.— Laminectomy.  The  laminae  have  been  cut  away  and  the  spinal 
canal  opened.  The  dura  mater  has  been  incised,  showing  the  spinal  cord  and 
the  nerve-roots  as  they  perforate  the  dura. 


540  ABDOMEN  AND  BACK. 

the  anterior  wall  of  the  spinal  canal  due  to  fracture,  dislocation, 
Pott's  disease,  should  be  corrected  by  reduction  or  by  chiseling  or 
gouging  away  the  offending  process  of  bone;  carious  bone  may  be 
curetted  and  sequestra  removed  and  the  cavity  which  remains  filled 
with  melted  paraffin  and  iodoform. 

In  order  to  reach  the  anterior  wall  of  the  canal,  it  may  be  neces- 
sary to  divide  several  nerve-trunks  upon  one  side  and  lift  the  cord 
partly  out  of  its  bed.  The  severed  nerves  may  be  reunited  afterward 
by  suture. 

If  the  cause  of  the  symptoms  is  not  apparent  the  dura  should 
be  laid  open.  Before  opening  the  dura,  its  color,  degree  of  bulging, 
pulsation,  etc.,  should  be  noted.  Bulging  of  the  dura  and  lack  of 
pulsation  indicate  pressure,  and  is  a  reason  for  incising  the  dura. 
The  dura  is  picked  up  with  a  toothed  forceps  and  a  small  opening 
made  in  the  middle  line,  and  through  this  opening  the  dura  is  incised 
upon  a  grooved  director  to  any  requisite  length.  When  the  dura  is 
incised  there  is  an  escape  of  cerebro-spinal  fiuid,  and,  may  be,  pus 
or  blood.  Precautions  should  be  taken  to  prevent  the  cerebro- 
spinal fluid  from  escaping  in  too  great  quantity.  It  may  be  dammed 
back  with  a  gauze  pad.  The  upper  part  of  the  body,  the  head,  should 
be  low.  If  there  are  any  adhesions  present  between  the  dura  mater 
and  the  arachnoid,  they  should  be  gently  broken  up.  The  edges  of 
the  dura  may  be  then  well  retracted  and  the  cord  carefully  examined. 
A  bent  probe  may  be  used  for  the  purpose  of  investigating  the  sides 
and  anterior  aspect  of  the  cord.  A  tumor  within  the  dura  may  be 
exposed  to  view.  Usually  of  the  nature  of  a  glioma,  endothelioma, 
fibroma,  gumma.  More  likely  to  be  situated  on  the  posterior  aspect 
or  side  of  the  cord,  is  frequently  encapsulated  and  may  be  enucleated 
by  gentle  manipulation  with  the  blunt  dissector.  The  tumor  may 
involve  the  nerve-roots^ — the  latter  may  be  so  intimately  incorporated 
with  the  tumor  mass  that  it  vsdll  be  necessary  to  resect  them  with  the 
tumor. 

If  the  symptoms  indicate  the  presence  of  a  tumor  and  none  is 
found,  it  is  advisable  to  resect  the  laminae  of  several  vertebrae  higher 
up  in  further  search  for  the  cause  of  the  trouble  If  the  tumor  is 
found  to  be  irremovable  the  posterior  nerve-roots  may  be  divided 
above  and  below  the  site  of  the  tumor  in  order  to  relieve  pain. 

In  closing  the  wound  the  edges  of  the  dura  are  brought  together 
with  interrupted  catgut  sutures  placed  about  one-eighth  inch  apart, 
and  the  edges  of  the  muscles  and  skin  approximated  with  interrupted 


OPERATIONS  UPON  THE  SPINAL  COLUMN.  54I 

sutures  of  silkworm  gut.  For  the  pui-pose  of  drainage,  a  narrow  strip 
of  gauze  is  introduced  into  the  bottom  of  the  wound,  its  extremity 
emerging  through  the  lower  end  of  the  skin  incision.  The  wound 
usually  heals  by  first  intention. 

The  parts  may  be  immobilized,  if  necessary,  by  incasing  the 
patient  in  a  plaster-of- Paris  jacket  or  by  the  use  of  a  proper  extension 
apparatus. 

Division  of  the  Posterior  Nerve-roots,  for  uncontrollable 
pain,  usually  involving  the  nerves  of  the  upper  extremity.  Amputation 
may  already  have  been  done  for  this  condition  without  relief.  The 
posterior  nerve-roots  may  also  be  divided  in  cases  of  inoperable, 
irremovable  tumor  of  spinal  cord  in  order  to  afford  relief  from  pain. 
Laminectomy  is  done  and  the  dura  opened.  The  posterior  nerve-roots 
are  picked  up  upon  a  blunt  hook  in  their  course  from  their  origin 
at  the  side  of  the  cord  to  the  foramina  in  the  dura,  through  which 
they  escape  and  are  divided  or  a  section  may  be  removed.  Owing  to 
the  fact  that  a  given  area  is  supplied  by  fibers  derived  from  different 
sources — from  several  segments  of  the  cord — it  is  necessary  to  divide, 
in  addition,  the  roots  of  one  or  two  nerves  above  and  below  the  nerve 
which  corresponds  directly  to  the  site  of  pain.  The  proper  nerve- 
roots  may  be  identified  by  stimulating  the  anterior  motor  roots  and 
observing  which  muscles  respond,  etc. 

Lumbar  Puncture. — J.  Leonard  Corning,  of  New  York,  in  1885 
reported  experiments  of  injecting  solutions  of  cocain  into  the  spinal 
canal  through  a  puncture  in  the  dorsal  region  for  the  purpose  of  in- 
ducing analgesia,  etc. 

Quincke,  of  Kiel,  in  1891,  practiced  lumbar  puncture  for  the 
purpose  of  drawing  off  fluid  to  diminish  intracranial  pressure  in  cases 
of  hydrocephalus.  With  this  object  in  view  he  drew  off  as  much 
as  100  c.c.  in  some  cases. 

Bier  in  1889  reported  a  number  of  cases  which  had  been  oper- 
ated upon  painlessly  under  the  influence  of  cocain  introduced  into 
the  subarachnoid  space  through  a  lumbar  puncture. 

Tuffier  in  1899  brought  the  matter  prominently  before  the  gen- 
eral profession,  and  since  then  the  method  has  been  practiced  by 
many  operators  with  much  success,  especially  in  cases  where  the  ad- 
ministration of  a  general  angesthetic  would  be  dangerous.  Lumbar 
puncture  is  also  practiced  for  the  purpose  of  withdrawing  the  cerebro- 
spinal fluid  for  examination  to  assist  in  diagnosing  cases  of  suspected 
cerebro-spinal    and    tuberculous    meningitis,    suspected    intracranial 


542  ABDOMEN  AND  BACK. 

hemorrhage,  fracture  of  the  base  of  the  skull,  etc.,  and  also  for  the 
purpose  of  introducing  therapeutic  agents,  antitoxin  in  tetanus,  etc.^ 
into  the  subarachnoid  space.  The  necessary  instruments  consist  of 
a  needle  and  syringe.  The  needle  may  be  made  of  steel  or,  better, 
of  iridium-platinum,  9  to  10  cm.  long,  with  a  diameter  of  1  mm.,  and 
provided  with  a  stylet.  A  needle  without  a  stylet  may  be  used,  but 
this  may  become  plugged.  It  has  the  advantage,  however,  of  showing 
just  as  soon  as  it  enters  the  subarachnoid  space  by  the  escape  of 
cerebro-spinal  fluid.  A  shorter  needle — 4  or  5  cm. — may  be  used 
for  children.  A  syringe  with  a  capacity  of  2  c.c.  and  capable  of 
being  sterilized  by  boiling — preferably  all  glass — is  employed. 

The  puncture  is  usually  made  between  the  lamina  of  the  fourth 
and  fifth  lumbar  vetebrse  or  between  the  third  and  fourth  or  the 
fifth  and  first  sacral.  The  puncture  between  the  laminae  of  the  fourth 
and  fifth  seems  to  be  preferred  by  most  surgeons. 

Krause  advises  introducing  the  needle  in  the  middle  line,  just 
under  the  spinous  process  of  the  second  lumbar  vertebra. 

The  patient  should  be  seated  upon  the  side  of  the  table  with 
his  back  to  the  operator,  his  trunk  bent  forward,  and  his  elbows 
resting  upon  the  thighs.  The  tips  of  the  spinous  processes  should 
form  a  straight  line  from  above  downward,  deviating  neither  to  the 
right  nor  left.  It  may  be  necessary  to  make  the  puncture  with  the 
patient  in  the  recumbent  position.  Under  these  circumstances  the 
patient  lies  upon  the  side  with  the  body  bent  and  the  knees  drawn 
up  to  the  abdomen.  The  skin  is  wiped  with  alcohol  and  then  painted 
with  iodine. 

To  locate  the  tip  of  the  spinous  process  of  the  fourth  lumbar 
vetebra,  which  is  usually  the  guide  in  performing  the  operation,  a 
line  may  be  drawn  across  the  back  from  the  highest  point  of  one 
iliac  crest  to  a  corresponding  point  upon  the  other.  The  tip  of 
the  spinous  process  of  the  fourth  lumbar  will  be  found  to  correspond 
to  this  line.  The  patient  being  bent  forward  causes  the  space  between 
the  laminae  of  the  fourth  and  fifth  lumbar  vertebrae  to  become  wider. 
The  index  finger  of  the  left  hand  is  placed  upon  the  lower  part  of 
the  tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra,  and 
with  the  right  hand  the  needle  is  introduced;  it  is  entered  just 
below  and  about  1  cm.  to  the  right  of  this  point  (tip  of  the  spine  of 
the  fourth  lumbar) .  The  skin  may  be  anaesthetized  and  a  small  in- 
cision made  with  the  point  of  the  knife  in  order  to  permit  the  easy 
passage   of  the  needle  through  this   structure,   which  is  sometimes 


OPERATIONS  UPON  THE  SPINAL  COLUMN.  543 

pretty  tough  and  difficult  to  penetrate.  The  needle  is  then  pushed 
slowly  and  deliberately  forward  and  inward  through  the  soft  parts, 
entering  the  spinal  canal  in  the  middle  line  between  the  lamiiias  of 
the  fourth  and  fifth  lumbar  vertebrje.  After  the  needle  has  passed 
through  the  ligament  between  the  laminae,  ligamentum  subflavum, 
and  the  dura  mater  into  the  subarachnoid  space  there  is  felt  a  sense 


Fig.  242.— Lumbar  Puncture.  Tip  of  spinous  process  of  fourth  lumbar 
vertebra  corresponds  to  a  line  drawn  across  the  back  touching  the  highest 
point  of  each  iliac  crest.  The  needle  is  inserted  just  below  and  to  right  of 
the  tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra. 

of  diminished  resistance  which  is  readily  appreciated,  especially  by 
the  experienced.  The  positive  proof  that  the  extremity  of  the  needle 
is  in  the  subarachnoid  space  is  the  escape  of  the  clear  cerebro-spinal 
fluid,  which  flows  from  the  end  of  the  needle  drop  by  drop  when 
the  stylet  is  withdrawn.  Not  more  than  about  5  c.c.  of  the  cerebro- 
spinal fluid  in  the  child  or   10  c.c.  in  the  adult  should  be  with- 


544  ABDOMEN  AND  BACK. 

drawn.  If  the  puncture  has  been  made  for  diagnostic  purposes  the 
fluid  is  caught,  drop  b}^  drop,  in  a  sterile  glass  vessel.  Occasionally 
the  pressure  of  the  cerebro-spinal  fluid  may  be  so  increased  that  the 
fluid  escapes  with  considerable  force  from  the  needle.  If  some  anal- 
gesic solution  or  antitoxin,  etc.,  is  to  be  introduced,  the  syringe  con- 
taining the  flud  is  adjusted  to  the  needle  and  the  contents  slowly 
injected.  Unless  the  escape  of  the  cerebro-spinal  fluid  occurs  to 
indicate  positively  that  the  end  of  the  needle  is  in  the  subarachnoid 
space  the  injection  should  not  be  made.  Fluid  is  usually  reached  at 
a  depth  of  4  to  7  cm.  in  adults  and  2  to  3  cm.  in  children. 

If  the  needle  strikes  an  impedihient  (bone)  on  the  way,  it  should 
be  partly  withdrawn  and  its  direction  changed  so  as  to  avoid  the 
obstruction.  One  should  not  attempt  to  forcibly  change  the  course 
of  the  needle  by  bending  it  without  withdrawing  it  at  least  in  part, 
as  it  may  break  off;  a  sudden  movement  or  jerk  on  the  part  of  the 
patient  may  also  break  the  needle. 

The  skin  is  rendered  sterile  in  the  usual  manner,  scrubbing,  etc., 
or  by  painting  with  iodine. 


PART  VI. 

THE  RECTUM. 

Surreal  Anatomy  of  the  Rectum. — The  rectum  is  the  ter- 
mination of  the  alimentary  canal  and  is  contained  within  the  true 
pelvis.  The  true  pelvis  is  bounded  in  front  by  the  symphysis  pubis 
and  by  the  bodies  and  rami  of  the  pubic  bones.  On  either  side  by  the 
body  and  ramus  of  the  ischium  and  toward  the  back  by  the  greater 
and  lesser  sacro-sciatic  ligaments,  which  fill  in,  to  a  large  extent, 
the  space  between  the  ischium  and  the  side  of  the  sacrum  and 
coccyx.  Behind  the  pelvic  cavity  is  bounded  by  the  sacrum  and  coccyx. 
The  pelvic  cavity  is  much  less  roomy  in  males  than  in  females. 

The  Sacrum  is  an  irregular,  triangular— shaped  bone  formed 
by  the  coalescence  of  five  vertebrae.  With  the  coccyx  it  forms  the 
lower  part  of  the  vertebral  column  and  the  posterior  wall  of  the 
pelvis,  where  it  is  wedged  in  between  the  ossa  innominata. 

It  is  flattened  from  before  backward  and  curved  upon  itself, 
and  is  placed  very  obliquely,  so  that  its  anterior  surface  looks  down- 
ward as  well  as  forward.  Above,  it  articulates  with  the  fifth  lumbar 
vertebra,  forming  a  prominent  angle  which  projects  forward  and 
forms  the  back  part  of  the  inlet  into  the  true  pelvis.  Its  lower  end 
articulates  with  the  base  of  the  coccyx.  The  lateral  borders  of  the 
sacrum  are  broad  and  irregular  above,  for  articulation  with  the  iliac 
bones  and  for  the  attachment  of  the  posterior  sacro-iliac  ligaments. 
The  lower  part  of  the  lateral  border  is  thin,  and  gives  attachment 
to  the  greater  and  lesser  sacro-sciatic  ligaments  and  to  a  portion  of 
the  gluteus  maximus  muscle.  Its  anterior  surface  is  smooth,  con- 
cave, looks  downward  and  forward,  and  presents  on  either  side,  one 
below  the  other,  the  four  anterior  sacral  foramina,  through  which 
openings  the  anterior  sacral  nerves  escape  from  the  sacral  canal. 
The  branches  which  emerge  from  th6  first,  second,  and  third  ante- 
rior sacral  foramina  are  large  and  go  to  form  the  sacral  plexus. 
Through  the  fourth  anterior  sacral  foramina  emerge  nerves  which 
are  distributed  to  the  rectum  and  the  bladder. 

The  posterior  surface  of  the  sacrum  is  convex,  rough,  and  irreg- 
ular. In  the  middle  line  from  above  downward  are  three  or  four 
tubercles,    which    represent    the    corresponding    spinous    processes; 

35  (545) 


546  RECTUM. 

iTSuall)^  the  fourth  and  always  the  fifth  are  absent.  External  to  the 
spinous  processes,  on  either  side  of  the  middle  line,  are  the  four 
posterior  sacral  foramina,  one  below  the  other.  These  provide  exit 
to  the  posterior  sacral  nerves,  which  are  of  no  importance  surgically. 
Between  the  posterior  sacral  foramina  and  the  spinous  processes  the 
bone  is  smooth,  and  corresponds  to  the  laminse  of  the  other  verte- 
bra, forming  the  posterior  wall  of  the  sacral  canal;  the  laminae  of 
the  fourth  usually  and  of  the  fifth  always  are  absent,  thus  leav- 
ing the  sacral  canal  open  at  its  lower  part.  The  margins  of  the 
laminse  below,  where  the  canal  is  open,  are  prominent,  and  are  called 
the  cornua.  They  articulate  with  the  corresponding  cornua  of  the 
coccyx.  The  posterior  surface  of  the  sacrum  is  covered  by  and  gives 
attachment  to  the  erector  spinge  muscle. 

The  Coccyx  is  formed  of  four  rudimentary  vertebrge,  and  con- 
tains no  spinal  canal.  Below,  at  the  tip,  the  coccyx  is  pointed  and 
gives  attachment  to  the  sphincter  ani.  Above,  it  presents  a  base 
with  a  prominent  process  on  each  side,  the  cornu.  Its  base  artic- 
ulates with  the  lower  end  of  the  sacrum;  its  cornua  articulate  with 
those  of  the  sacrum.  Its  lateral  border  gives  attachment  to  the 
greater  and  lesser  sacro-sciatic  ligaments,  to  the  coccygeus  muscle, 
and  low  down  near  its  tip  to  a  few  fibers  of  the  levator  ani  muscle. 

The  Eectum  is  the  terminal  part  of  the  alimentary  canal.  It 
is  continuous  with  the  sigmoid  flexure  (pelvic  colon)  above  and  ends 
below  at  the  anus.  The  rectum  is  about  eight  inches  long  and 
consists  of  two  parts :  the  first,  the  upper  dilated  part,  ampulla  recti; 
the  second  or  lower  part,  the  anal  canal,  pars  analis  recti. 

In  the  older  descriptions  the  rectum  is  considered  in  three  parts, 
an  upper,  a  middle  and  a  lower  portion.  The  upper  or  first  part 
of  the  rectum,  according  to  .the  older  descriptions,  reaches  from  the 
left  sacro-iliac  synchondrosis  to  the  level  of  the  third  sacral  vertebra. 
This  part  of  the  bowel  is  attached  by  a  long  mesentery  to  the  back 
part  of  the  pelvic  cavity  from  the  left  sacro-iliac  synchondrosis  to 
the  third  sacral  vertebra.  It  consists  of  a  large,  redundant  loop 
of  gut,  and  is  found  loose  and  freely  movable  within  the  pelvic 
cavity,  and  presents  all  the  characteristic  features  of  the  colon, 
appendices  epiploicse,  longitudinal  striae,  sacculations,  etc.  It  is 
therefore  better  to  consider  this  portion  of  the  bowel,  not  as  the 
first  part  of  the  rectum,  but  rather  as  a  part  of  the  sigmoid  flexure, 
or  as  a  separate  segment,  the  pelvic  colon.  According  to  this  plan 
the  rectum  consists  of  that  portion  of  the  bowel  only  which  reaches 


SURGICAL  AN AlOMY  OF  THE  RECTUM. 


547 


from  the  level  of  the  upper  border  of  the  third  sacral  vertebra  to 
the  anus,  and  may  be  described  as  consisting  of  two  parts,  an  upper 
dilated  part,  ampulla  recti,  and  a  lower  part,  the  anal  canal,  or  pars 
analis  recti. 

The  Upper  Part  of  the  Rectum,  the  ampulla  recti,  is  five  or 
six  inches  long.  It  is  roomy  and  dilatable  and  begins  about  on  a 
level  with  the  upper  border  of  the  third  sacral  vertebra,  and  terminates 
by    passing    through    the    pelvic    floor    (between    the    levatores    ani 


Fig.  243.— The  Rectum.  The  portion  below  the  peritoneal  fold  is  represented 
as  cut  in  transverse  section.  The  three  lateral  curves  are  shown;  below,  in 
the  cross-section,  the  lowest  of  the  three  valves  of  Houston.  L.A.,  levator  ani, 
covered  upon  its  upper  surface  by  the  pelvic  fascia;  upon  its  under  surface,  by 
the  anal  fascia.  0.,  obturator  internus  covered  over  by  the  obturator  fascia. 
P.,  cut  edge  of  peritoneal  fold  that  is  reflected  from  the  anterior  wall  of  the 
rectum  forward  on  to  the  posterior  wall  of  the  bladder  in  the  male;  on  to  the 
upper  part  of  the  posterior  wall  of  the  vagina  and  the  uterus,  in  the  female. 
S.E.,  external  sphincter  ani.  8. 1.,  internal  sphincter  ani.  The  three  layers  of 
the  wall  of  the  rectum,  the  mucous  and  the  circular  and  longitudinal  muscular 
layers  are  shown  on  section. 

muscles)  opposite  the  lower  border  of  the  prostate  (in  the  male),  to 
become  continuous  with  the  anal  canal  (pars  analis  recti).  This  part 
of  the  rectum  presents  an  antero-posterior  curve  with  its  convexity 
baclcward  corresponding  to  the  hollow  of  the  sacrum  and  coccyx.  It 
also  presents  three  lateral  curves  with  well-marked  indentations.  The 
uppermost  curve  with  its  convexity  toward  the  right;  the  middle 
curve,  the  most  prominent,  with  its  convexity  toward  the  left,  and 
the  lowest,  with  its  convexity  to  the  right  and  Just  above  the  point 


548  RECTUM. 

where  this  part  of  the  rectum  becomes  continuous  with  the  anal  canal. 
Corresponding  to  the  concavity  of  each  of  these  lateral  curves  the 
wall  of  the  rectum  is  sharply  indented  so  that  three  corresponding 
icrescentic,  valve-like  shelves  are  made  to  present  into  the  lumen  of 
the  rectum.  These  folds  are  called  the  pUcce  transversales  recti,  or 
the  valves  of  Houston,  They  serve  to  support  the  weight  of  the 
rectal  contents. 

The  wall  of'  the  upper  part  of  the  rectum  is  thick  and  consists 
of  a  mucous  and  submucous  layer  and  a  thick  muscular  coat.  The 
muscular  coat  is  made  up  of  two  layers:  an  external,  longitudinal, 
and  an  internal,  circular,  layer.  The  longitudinal  fibers  are  more 
numerous  anteriorly  and  posteriorly,  and  thus  form  two  prominent, 
thick  bands,  one  in  front  and  the  other  behind.  These  bands  are 
relatively  short  and,  as  a  result,  cause  the  rectxmi  to  assume  the  three 
lateral  curves  described  above.  The  fibers  of  the  levatores  ani  where 
they  are  attached  to  the  rectum  are  interwoven  with  the  longitudinal 
muscular  fibers  of  the  rectal  wall. 

The  peritoneum  covers  the  front  and  sides  of  the  upper  part  of 
this  portion  of  the  rectum,  but  below  it  covers  the  anterior  aspect 
only.  The  rectum  has  no  mesentery.  Its  posterior  wall  is  in  rela- 
tion with  a  mass  of  loose  connective  tissue  which  is  interposed  between 
it  and  the  anterior  surface  of  the  sacrum.  Below,  the  peritoneum 
is  reflected  from  the  front  surface  of  the  rectum  on  to  the  bladder 
in  the  male,  above  the  location  of  the  seminal  vesicles,  and  about  one 
inch  above  the  base  of  the  prostate.  In  the  female  the  peritoneum  is 
reflected  on  to  the  upper  one-fourth  of  the  posterior  wall  of  the 
vagina  and  thence  upward  upon  the  posterior  surface  of  the  uterus. 
It  forms  the  pouch  of  Douglas,  between  the  front  of  the  rectum  and 
the  posterior  wall  of  the  vagina.  The  rectum  is  in  relation  posteriorly 
with  the  sacrum  and  coccyx,  a  considerable  mass  of  loose  connective 
tissue  and  the  lymph-nodes  that  receive  the  hmiphatics  from  the 
rectum  intervening.  In  the  space  behind  the  rectum  the  superior 
hemorrhoidal  artery,  the  continuation  of  the  inferior  mesenteric,  de- 
cends  to  supply  this  part  of  the  rectum,  Below,  in  the  male,  this 
part  of  the  rectum  is  in  relation,  anteriorly,  with  the  base  of  the 
bladder,  vasa  deferentia,  vesicula3  seminales,  and  the  prostate  gland. 
In  the  female,  this  part  of  the  rectum  is  in  relation  anteriorly  with 
the  posterior  wall  of  the  vagina. 

The  Lov^ee  Part  of  the  Eectum,  the  pars  analis  recti,  is  about 
one  and  one-half  inches  long  and  reaches  from  the  level  where  the 


SURGICAL  AXAT0:\1Y  OF  THE  RECTUM.  549 

rectum  pierces  the  muscular  pelvic  floor  {levatoi-es  ani)  to  the  cutane- 
ous margin  of  the  anal  orifice.  Corresponding  to  this  part  of  the 
rectum  the  circular  muscular  fibers  are  greatly  increased  in  number 
and  form  a  strong  muscular  bundle,  the  internal  sphincter.  This 
muscle  surrounds  the  entire  length  of  the  anal  portion  of  the  rectum. 

The  Levatores  Ani  Muscles  form  the  chief  part  of  the  floor 
of  the  true  pelvis.  They  arise  from  the  inner  aspect  of  the  front  and 
side  walls  of  the  pelvic  cavity.  They  take  their  origin  anteriorly 
from  the  posterior  surface  of  the  pubic  bone:  upon  the  sides  they 
arise  from  the  fascia  that  covers  the  inner  surface  of  the  obturator 
internus  muscles,  along  the  "white  line,"  back  as  far  as  the  spine 
of  the  ischium.  The  fiber?  of  the  muscles  of  both  sides  pass  down- 
ward, backward  and  inward,  joining  in  the  middle  line  to  form  the 
muscular  floor  of  the  pelvis.  Those  fibers  of  the  levatores  ani  that 
arise  from  the  posterior  surface  of  the  pubic  bone,  and  which  cor- 
respond to  the  inner  edge  of  each  muscle,  pass  backward  and  inward, 
some  joining  together  in  front  of  the  rectum,  the  others  being  inserted 
into  tfie  sides  of  the  rectum.  Those  fibers  of  the  levatores  ani  that 
arise  from  the  anterior  part  of  the  "white  line"  join  together  behind 
the  rectum,  thus  filling  in  this  posterior  part  of  the  pelvic  floor — 
from  the  rectum  to  the  coccyx — and  are  inserted  into  the  tip  and 
sides  of  the  coccyx.  The  fibers  that  arise  from  the  posterior  part 
of  the  "white  line"  as  far  back  as  the  spine  of  the  ischium — are 
attached  to  the  sides  of  the  coccyx.  Those  fibers  of  the  levatores  ani 
which  are  inserted  into  the  sides  of  the  rectum  are  interwoven  with 
the  longitudinal  muscular  fibers  of  the  rectal  wall  and  below  with 
the  fibers  of  the  external  sphincter. 

The  upper  surface  of  the  levatores  ani  is  covered  over  by  a  layer  of 
fascia  which  is  derived  from  the  pelvic  fascia.  Where  the  rectum 
penetrates  between  the  levatores  ani  this  fascia  is  reflected  upward 
upon  the  rectum  and  thus  serves  to  materially  strengthen  its  wall. 

Anteriorly,  there  is  a  space  between  the  levatores  ani  which  is 
filled  in  by  a  dense  fascia,  the  posterior  or  deepjayer  of  the  deep 
perineal  fascia  or,  as  it  is  sometimes  called,  the  triang-ular  ligament. 
This  fascia  forms  the  uro-genital  diaphragm — the  trigonum  uro- 
genitale — and  is  perforated  in  the  male  by  the  urethra,  in  the  female 
by  the  urethra  and  vagina.  Farther  back  the  levatores  ani  are 
attached  to  the  sides  of  the  rectum,  which  is  gripped  tightly  between 
the  two  muscles  at  the  point  where  the  upper  portion  of  the  rectum, 
ampulla  recti,  penetrates  between  the  muscles  to  become  the  anal 


550  RECTUM. 

canal.  Posterior  to  the  rectum — ^between  the  rectum  and  coccyx — 
the  muscles  join  together  in  the  middle  line  to  close  in  this  posterior 
part  of  the  pelvic  floor. 

Corresponding  to  the  level  where  the  fibers  of  the  levatores  ani 
are  attached  to  the  rectum,  at  the  junction  of  the  upper  part  and  the 
anal  portion,  the  rectum  presents  a  constricted  appearance  caused  by 
its  being  gripped  by  the  levatores  ani  at  this  point.  The  levatores  serve 
to  support  the  rectum  by  suspending  it  from  the  anterior  and  lateral 
Myalls  of  the  true  pelvis.  The  levatores,  by  their  contraction,  close 
the  anal  canal  and  lift  the  rectum  and  pelvic  floor. 

In  the  quiet  state  the  lumen  of  the  anal  portion,  as  a  result  of 
the  tonic  contraction  of  the  levatores  ani  and  the  external  sphincter, 
is  obliterated,  being  reduced  to  a  mere  slit-like  passage.  The  anal 
portion  of  the  rectum  has  a  direction  from  above  downward  and 
jbackward,  and  forms  almost  a  right  angle  with  the  upper  portion 
of  the  rectum.  When  the  finger  is  introduced  into  the  anal  canal 
it  should,  therefore,  be  in  a  direction  upward  and  forward. 

The  lower  part  of  the  anal  canal  is  surrounded  by  a  strong 
bundle  of  striped  muscle  fibers,  the  external  sphincter.  This  muscle 
arises  from  the  tip  of  the  coccyx  and  passes  forward  upon  either 
side  of  the  anal  opening  to  be  attached  in  front  to  the  mid-point  of 
the  perineum.  This  muscle  and  the  levatores  ani  are  both  under 
control  of  the  will.  Under  ordinary  quiet  conditions,  by  their  con- 
stant contraction,  they  serve  to  maintain  the  anal  canal  closed. 

The  anal  portion  is  in  relation  behind  with  a  wad  of  connective 
and  muscular  tissue  that  lies  between  it  and  the  coccyx — the  ano- 
coccygeal body.  Anteriorly,  in  the  male,  the  anal  portion  is  in  rela- 
tion with  the  bulb  of  the  urethra.  In  the  female  it  is  in  relation, 
anteriorly,  with  the  perineal  body,  which  intervenes  between  it  and 
the  vagina. 

The  upper  portion  of  the  rectum  is  voluminous  and  capable  of 
considerable  distention,  and  is  called  the  ampulla  and  presents  three 
crescentic  folds :  ylicoe  trcmsversales  recti,  valves  of  Houston.  These 
folds  are  caused  by  the  indentation  of  the  wall  of  the  rectum,  and 
include  both  the  mucous  and  circular  muscular  layers.  The  most 
marked  and  constant  of  these  folds  is  located  about  half-way  up,  upon 
the  right  wall^6  to  8  cm.  above  the  anal  orifice  and  about  on  a 
level  with  Douglas's  fold.  The  two  others  are  upon  the  left  wall, 
not  so  constant  nor  so  prominent,  and  are  placed  one  nearer  and  the 
other  farther   aAvav   from   the   anus   than   the    one   first   mentioned. 


SURGICAL  ANATOMY  OF  THE  RECTUM.  551 

These  folds  may  offer  considerable  obstruction  to  the  passage  onward 
of  bougies,  etc.  They  serve  to  support  the  weight  of  the  contents 
of  the  rectum. 

The  walls  of  the  anal  portion,  in  the  quiet  state,  are  in  contact. 
The  lumen  is  obliterated  and  upon  section  appears  as  a  mere  antero- 
posterior slit.  The  mucous  membrane  of  the  anal  canal  presents  a 
number  of  longitudinal  folds,  six  to  ten,  called  the  columns  of 
Morgagni. 

The  skin  about  the  anus  is  thrown  into  folds,  which  radiate 
toward  the  anus,  and  often  in  the  form  of  tags,  etc.,  may  become 
hypertrophied,  inflamed,  and  itch — external,  or  itching,  piles;  or 
a  small  varicosed  vein  may  rupture  into  one  of  them — hemorrhagic 
pile;  or  they  may  present  cracks  or  fissures  between  them,  at  the 
edge  of  the  anus — fissure  in  ano. 

The  Blood-supply  of  the  Eectum  is  derived  chiefly  from  the 
superior  hemorrhoidal  artery,  which  is  the  continuation  of  the  in- 
ferior mesenteric.  The  inferior  mesenteric  passes  into  the  pelvis 
between  the  two  layers  of  the  mesentery  of  the  sigmoid  flexure  (pelvic 
colon) .  As  the  superior  hemorrhoidal  it  descends  behind  the  rectum. 
About  the  middle  of  the  rectum  it  divides  into  two  lateral  hemor- 
rhoidal arteries,  which  descend  upon  either  side  of  the  rectum,  break- 
ing up  into  a  number  of  branches  which  anastomose  with  branches 
from  the  middle  hemorrhoidal  and  pierce  the  wall  of  the  rectum 
to  supply  it.  The  middle  hemorrhoidal  arteries  are  given  off  from 
the  anterior  division  of  the  internal  iliac  and  are  distributed  upon 
the  lateral  wall  of  the  rectum.  The  inferior  hemorrhoidal  arteries, 
several  on  each  side,  are  derived  from  the  internal  pubic.  They  pass 
inward  across  the  ischio-rectal  space,  toward  the  lower  end  of  the 
rectum  and  anus  to  supply  these  parts.  The  branches  of  all  three 
hemorrhoidal  arteries  anastomose  freely  with  each  other,  up  and  down 
the  wall  of  the  rectum. 

The  veins  that  drain  the  rectum  originate  in  a  plexus  in  the 
submucous  layer  which  presents  numerous  sac-like  dilatations  just 
above  the  anal  orifice.  The  veins  pierce  the  wall  of  the  rectum  to 
form  a  plexus  upon  the  external  surface  of  the  wall  of  the  rectum 
— ^the  external  hemorrhoidal  plexus.  This  plexus  is  drained  by  the 
superior  hemorrhoidal  vein  which  passes  upward  in  the  connective- 
tissue  space  behind  the  rectum,  in  company  with  the  superior  hemor- 
rhoidal artery,  to  become  continuous  with  the  inferior  mesenteric. 
The  blood  carried  by  the  superior  hemorrhoidal  is  therefore  discharged 


552  RECTUM. 

into  the  portal  system  and  must  first  pass  through  the  liver  before 
it  reaches  the  right  side  of  the  heart.  The  superior  hemorrhoidal 
vein  has  no  valves.  The  middle  and  inferior  hemorrhoidal  veins 
are  formed  by  branches  of  the  external  hemorrhoidal  plexus.  They 
empty;,  the  middle  hemorrhoidal,  into  the  internal  iliac  vein,  and, 
the  inferior  hemorrhoidal,  into  the  internal  pudic.  The  middle  and 
inferior  hemorrhoidal  veins  have  valves.  The  blood  carried  by  these 
veins  finds  its  way  to  the  heart  through  the  vena  cava.  The  venous 
plexus  situated  in  the  submucous  layer,  in  the  lower  part  of  the 
rectum,  just  above  the  external  sphincter,  is  tortuous,  and  in  certain 
conditions — obstruction  of  the  portal  circulation  (the  superior  hemor- 
rhoidal vein  has  no  valves),  habitual  constipation,  pressure  of  the 
gravid  uterus,  etc. — ^may  become  enlarged,  pouched  and  varicose,  and 
give  rise  to  the  condition  known  as  "bleeding  piles,"  or  internal 
hemorrhoids.  Through  the  veins  which  drain  the  rectum  infection 
may  be  carried  to  the  portal  vein,  liver — abscess  of  the  liver,  etc. 

The  Lymphatics  that  drain  the  rectum — the  upper  part — 
originate  in  the  submucous  layer  and  terminate  in  the  lymph-nodes 
that  are  situated  in  the  loose  connective  tissue  in  the  space  behind 
the  rectum,  between  the  rectum  in  front  and  the  sacrum  behind,  and 
are  continued  in  a  chain  upward  along  the  course  of  the  iliac  vessels. 
In  the  space  behind  the  rectum  and  along  the  course  of  the  iliac 
vessels,  especially  upon  the  left  side,  are  the  affected  lymph-nodes 
to  be  sought  in  cancer  of  the  rectum.  The  smallest  lymphatics 
originate  and  ramify  in  the  submucous  layer.  The  disease  spreads 
by  permeation  of  the  submucous  layer  with  cancer  cells.  The  wall 
of  the  rectum  may  thus  be  affected  for  some  distance  above  the 
apparent  upper  limit  of  the  disease ;  hence  the  necessity  for  resecting 
the  rectum  several  inches,  at  least  two  inches,  above  the  apparent 
limit  of  the  disease. 

The  lymph-vessels  that  drain  the  anal  portion  of  the  rectum 
terminate  in  the  inguinal  glands,  which  therefore  become  affected 
early  in  malignant  disease  of  this  part  of  the  rectum. 

The  left  ureter,  as  it  descends  into  the  pelvis,  over  the  bifurcation 
of  the  common  iliac  artery,  is  in  close  relation  to  the  inferior 
mesenteric  artery  and  vein  and  to  the  iliac  group  of  glands  that  are 
frequently  found  involved  in  cancer  of  the  rectum. 

The  nerves  that  emerge  from  the  first,  second,  and  third  ante- 
rior sacral  foramina  join  with  each  other  to  form  the  sacral  plexus. 
The  rectum  is  supplied  by  nerves  that  emerge  through  the  fourth 


OPERATIONS  UPOX  THE  ANUS  AND  RECTUM.       553^ 

anterior  sacral  foramen.     Branches  from  these  nerves  are  also  dis- 
tributed to  the  bladder. 

OPERATIONS  UPON  THE  ANUS  AND  RECTUM. 

Dilatation  of  the  Sphincter. — This  operation  is  practiced  as  a 
curative  measnre  for  fissure  in  ano  and  as  a  preliminary  step  in  other 
operations  npon  the  anus  and  rectum. 

The  patient  is  placed  in  the  lithotomy  position.  Under  anaes- 
thesia two  fingers  or  the  thumb  of  each  hand  are  introduced  through 
the  anus  and  well  up  into  the  rectum  beyond  the  level  of  the  internal 
sphincter,  and  a  gradually  increasing  steady  force  is  exerted  in  a 
lateral    direction    toward   either   tuber   ischii   until   the    sphincter  is 


Fig.  244. — Complete  Fistula  in  Ano.     L.A.,   levator  ani;  8.E.,  external  sphincter; 
S.I.,   internal   sphincter.     Dark  portion  represents  the  fistula. 

thoroughly  relaxed.  Considerable  force  may  be  employed,  but  it 
should  be  applied  gradually,  and  not  abruptly.  In  cases  where  the 
stretching  of  the  sphincter  is  done  for  fissure  the  sphincter  is  para- 
lyzed and  the  parts  thus  placed  at  rest  so  that  they  can  heal.  Mere 
stretching  of  the  sphincter  will  cure  many  cases  of  hemorrhoids. 

Fistula  in  Ano. — This  may  be  either  complete  or  incomplete. 
The  incomplete  may  be  either  blind  external  or  blind  internal. 

A  complete  fistula  is  a  tract,  or  sinus,  which  opens  internally 
into  the  rectum  and  externally  upon  the  skin  near  the  margin  of 
the  anus,  and  may  allow  the  escape  of  gas  and  fsecal  material  from 
the  bowel. 

The  opening  into  the  rectum  is  usually  single,  but  there  may  be 
several  openings  upon  the  skin  about  the  anus. 

If  the  finger  is  introduced  into  the  rectum  and  a  probe  passed 
into  the  fistula  through  the  opening  in  the  skin,  its  point  may  be 
felt  beneath  the  rectal  mucous  membrane  and  may  be  guided 
through  the  inner  orifice  of  the  fistula  into  the  rectum.    This  open- 


554 


EECTUM. 


ing  will  be  found  a  variable  distance  above  the  anal  orifice  and  at 
times  may  be  somewhat  difi&eult  to  discover;  it  may  be  located  above 
the  internal  sphincter  or  it  may  be  just  above  the  external  sphincter 
close  to  the  margin  of  the  anus. 

An  incomplete,  or  blind,  fistula  is  one  which  presents  an  orifice 
at  only  one  end.  If  it  opens  into  the  rectum,  but  not  externally 
upon  the  skin,  it  is  called  a  blind  internal  fistula;  if  it  opens  ex- 
ternally upon  the  skin,  but  not  internally  into  the  rectum,  it  is  called 
a  blind  external  fistula. 

Opeeation  foe  Complete  Fistula. — The  anus  is  first  thor- 
oughly stretched.  The  finger  is  then  introduced  into  the  rectum 
and  a  blunt-pointed  grooved  director  passed  into  the  fistula  through 
the  opening  in  the  skin.     The  point  of  the  director,  which  may  be 


Fig.  245.— Blind  Internal  Fistula. 


recognized  by  the  finger  in  the  rectum  beneath  the  rectal  mucous 
membrane,  is  guided  into  the  bowel  through  the  internal  orifice  of 
the  fistula.  It  is  important  to  find  this  opening.  The  end  of  the 
director  is  then  brought  out  through  the  anus, — the  director  may 
be  bent  somewhat  in  order  to  do  this, — and  the  bridge  of  tissue 
upon  the  director  is  divided  with  the  knife,  carried  along  the  groove 
of  the  director;  the  fistula  is  thus  laid  open  through  its  whole 
length  into  the  rectum.  If  there  is  more  than  one  external  orifice 
upon  the  skin,  the  intervening  tissue  between  the  separate  open- 
ings should  be  divided.  Any  secondary  sinuses  branching  off 
from  the  main  fistulous  tract  should  also  be  laid  open.  Methylene 
blue  injected  into  the  fistula  may  help  identify  the  fistulous  tract  and 
its  various  ramifications. 

In  searching  with  the  probe  for  additional  fistulous  tracts 
leading  off  from  the  main  tract,  care  must  be  exercised  not  to  make 
false  passages  by  forcing  the  probe  into  the  healthy  loose  tissue 
adjacent  to  the  fistula.    As  the  internal  orifice  of  the  fistula  is  above 


OPERATIONS  UPOX  THE  ANUS  AND  RECTUM.  555 

the  external  sphincter  or  may  be  above  the  internal  sphincter,  these 
muscles  are  naturally  divided  when  the  fistula  is  laid  open.  The 
tract  of  the  sinus  may  be  curetted  after  it  has  been  laid  open,  but 
too  much  force  should  not  be  used.  The  whole  wound  is  finally 
packed  with  iodoform  gauze.  This  packing  should  not  be  too  tight, 
but  should  reach  well  to  the  bottom  of  the  wound  in  every  direction. 
The  bleeding  is  usually  readily  controlled  by  the  packing.  Any 
spurting  vessels  should  be  clamped  and  tied. 

A  dose  of  castor  oil  is  given  in  the  evening  of  the  third  day  and 
the  packing  removed  on  the  fourth  day. 

Operation  for  Incomplete  Fistula  is  practically  the  same 
as  the  foregoing.  If  there  is  no  opening  into  the  rectum, — a  blind 
external  fistula, — ^the  point  of  the  director,  which  is  passed  into  the 


Fig.  246.— Blind  External  Fistula. 

fistula  through  the  external  orifice  and  which  is  felt  beneath  the 
rectal  mucous  membrane  by  the  finger  within  the  rectum,  may  be 
forced  into  the  rectum,  the  sinus  being  thus  converted  into  a  com- 
plete fistula,  and  the  parts  then  divided  as  already  described. 

If  there  is  no  external  opening,^ — a  blind  internal  fistula, — ^we 
make  one.  The  skin  near  the  margin  of  the  anus,  at  the  point 
corresponding  to  the  blind  external  extremity  of  the  fistulous  tract, 
is  usually  marked  by  redness,  induration,  etc.  An  incision  is  made 
through  the  skin  at  this  point,  thus  converting  the  sinus  into  a  com- 
plete fistula,  which  is  then  treated  as  described  above — the  director 
is  introduced  through  the  fistula  into  the  rectum  and  the  entire 
fistulous  tract  laid  open. 

Hemorrhoids.— -External,  or  Itching,  Piles  present  them- 
selves about  the  margin  of  the  anal  orifice  outside,  external  to  the 
sphincter;  they  consist  of  cutaneous  tags,  which  may  be  snipped 
off  with  the  scissors,  the  edges  of  the  skin  being  then,  if  necessary, 
brought  together  with  a  single  suture.     Occasionally  they  contain 


556 


RECTUM. 


a  varicosed  vein  which  may  be  thrombosed  or  ruptured.  These  piles 
are  often  very  painful.  They  may  be  laid  open,  the  clot  turned  out,, 
and  the  edges  of  the  skin  brought  together  with  a  single  catgut 
suture.    Frequently  a  fissure  is  located  at  the  base  of  one  of  these  ex- 


Fig.  247. — Operation  for  Hemorrhoids.     An  hemorrhoidal  mass  is  seized  with 
the  clamp  and  a  collar  cut  in  its  base,  all  around,  through  the  mucous  mem- 
brane.    The  edges  of  the  incision  are   pushed  up   and  the  pile   drawn   down,    so 
as  to  obtain  a  pedicle  of  some  length. 

ternal  tags,  or  piles,  and  it  is  therefore  wise,  in  all  these  cases,  to 
stretch  the  sphincter  before  removing  the  pile. 

Intkeinal,  or  Bleeding,  Piles. — These  are  located  entirely 
within  the  anus,  only  appearing  externally  when  the  patient  strains, 
or  bears  down.  They  may  be  extruded  and  caught  in  the  grasp  of 
the  external  sphincter  and  become  strangulated.     When  the  patient 


OPERATIONS  UPON  THE  AXUS  AND  RECTUM. 


557 


strains  they  may  appear  as  one  or  more  fairly  well  defined  bunches. 
Each  mass  consists  of  one  or  more  arterial  twigs  and  a  bunch  of 
dilated,  pouched,  varicosed  veins  covered  over  by  mucous  membrane 
which  may  be  normal  in  appearance  or  may  be  more  or  less  ulcerated. 


Fig.  248.— Operation  for  Hemorrtioids.     The  pedicle  is  transfixed,   high   up,   with 
the  needle  carrying  the  catgut  ligature. 


Ligation  and  Excision. — The  sphincter  is  first  stretched  and 
the  rectum  thoroughly  irrigated.  Each  individual  hemorrhoidal 
mass  is  then  seized  with  a  clamp,  an  ordinary  artery  forceps,  and 
while  it  is  pulled  down  the  mucous  membrane  around  its  base  is  cut 
through  by  snipping  with  the  blunt-pointed,  scissors.  This  incision 
should   extend  through  the  mucous  membrane  all   around  the  base 


558  KECTUM. 

of  the  pile  into  the  submucous  connective-tissue  layer,  but  should 
not  cut  into  the  vessels  that  go  to  form  the  hemorrhoidal  mass.  After 
this  the  mucous  membrane  at  the  base  of  the  pile  is  peeled  back  for 
a  considerable  distance  with  the  finger-nail  or  with  the  end  of  the 
blunt-pointed  scissors,  with  the  result  that  the  pile,  in  the  grasp  of 
the  clamp,  hangs  by  its  pedicle,  which  consists  of  the  arterial  twig 
that  supplies  it  and  the  varicosed  veins.  The  base  or  pedicle  of  the 
pile  is  surrounded  with  a  strong  catgut  ligature  (No.  2,  plain  catgut), 
which  is  tied  very  tight  so  that  it  cannot  slip.  To  insure  the  ligature's 
not  slipping  the  pedicle  of  the  pile  may  be  transfixed  with  a  curved 
needle,  which  carries  the  ligature.     After  the  ligature  has  been  tied. 


Kg.  249.— Rectal  Tube  Wrapped  with  Gauze.  A  safety-pin  is  passed  tlirough 
the  end  of  the  tube.  The  tube  is  prevented  from  slipping  out  of  the  rectum 
by  the  tapes  which  pass  through  the  safety-pin,  being  tied  to  the  waistband  of 
the  T-bandage. 

the  pile  is  cut  away  close  to  the  ligature  and  the  ligature  then  cut 
short.  Each  hemorrhoidal  mass  is  treated  in  this  manner.  They 
usually  number  from  three  to  five  masses.  After  the  pile  has  been 
cut  away  the  edges  of  the  opening  in  the  mucous  membrane  will  be 
seen  to  fall  over  the  stump  of  the  pedicle  and  more  or  less  completely 
bury  it.  The  edges  of  the  opening  in  the  mucous  membrane  may  be 
brought  together  over  the  stump  of  the  pile  with  one  or  two  sutures 
of  plain  catgut.     As  a  rule,  however,  this  is  not  necessary. 

After  the  operation  has  been  completed  a  rubber  tube,  wrapped 
around  with  iodoform  gauze,  is  inserted  into  the  rectum.  The  tube 
and  gauze  should  reach  a  point  above  the  level  of  the  site  of  the 
operation.  The  gauze  wrapping  stops  the  oozing.  A  considerable 
hemorrhage  may  take  place  from  the  slipping  of  a  ligature  and  a  large 
quantity  of  blood  may  escape  into  the  bowel  without  any  appearing 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM.  559 

externally.  If  the  tube  has  been  inserted  and  should  this  accident 
occur,  the  blood  will  escape  through  the  tube  and  appear  externally 
and  give  warning.  The  tube  also  permits  the  escape  of  gas.  The 
gauze  may  be  smeared  with  sterile  vaseline  to  facilitate  its  intro- 
duction. The  tube  is  prevented  from  slipping  out  of  the  rectum  by 
two  bands  of  tape  which  are  fastened  to  a  safety-pin  in  the  end  of 
the  tube  and  tied  to  the  belt  of  the  T-bandage.  The  tube  is  left 
in  place  for  four  days.  On  the  evening  of  the  third  or  fourth  day 
a  dose  of  castor  oil  is  administered.  From  the  time  of  operation 
until  the  bowels  move  the  diet  is  restricted  to  broths,  albumin  water, 
etc. ;  no  milk  or  solids  that  would  leave  a  considerable  residue  in 
the  bowel  are  given. 

Clamp  and  Cautery  — After  the  sphincter  has  been  stretched, 
etc.,  each  pile  is  seized  at  its  most  prominent  part  with  an  artery 
forceps  and  drawn  well  down  and  a  special  clamp — pile  clamp- 
applied  to  its  base.  The  end  of  the  clamp  as  it  grasps  the  pile  should 
be  directed  upward  into  the  rectum;  i.  e.,  it  should  not  grasp  the 
hemorrhoidal  mass  along  a  line  parallel  with  the  margin  of  the  anus, 
as  this  would  result  in  an  annular  scar,  which  is  not  desirable.  The 
pile  is  firmly  caught  between  the  blades  of  the  clamp  and  completely 
crushed  by  turning  the  screw  down  tight.  The  pile  is  then  cut  away 
with  the  scissors,  rather  close  to,  but  not  flush  with,  the  surface  of 
the  blades  of  the  clamp;  a  small  part  of  the  tissue  should  be  left 
protruding  beyond  the  surface  of  the  clamp  after  the  pile  is  cut 
away.  The  cautery  at  a  red  heat  is  now  applied  to  the  cut  edge  of 
the  remaining  portion  of  the  pile  which  protrades  beyond  the  surface 
of  the  blades  of  the  clamp  and  this  is  slowly  burned  to  a  crisp  down 
to  the  surface  of  the  blades.  The  clamp  is  then  removed.  Each  pile 
is  treated  in  this  manner.  It  will  be  seen,  when  the  operation  is 
completed,  that  the  seared  lines  corresponding  to  the  several  piles 
that  have  been  burnt  off  all  radiate  up  into  the  rectum.  They 
should  not  join  each  other  to  form  an  annular  scar  around  the  anus. 
The  rectum  is  not  tamponed.  The  introduction  of  the  gauze  pack 
would  tend  to  open  the  seams  made  by  the  cautery  and  might  thus 
cause  bleeding. 

Prolapsus  Recti. — ^Lesser  degrees  of  this  condition  may  be  cor- 
rected by  minor  procedures;  by  cauterizing  the  prolapsed  portion — 
lines  made  with  the  actual  cautery  radiating  from  the  anal  margin 
up  into  the  rectum.  Another  plan  is  to  resect  the  prolapsed  portion 
and  then  suture  the  end  of  the  rectum  to  the  margin  of  the  anus.    If 


560  RECTUM. 

the  prolapse  is  due  to  the  presence  of  a  polyp,  hemorrhoids,  etc., 
these  conditions  should  he  corrected. 

SiGMOiDOPEXT. — This  operation  which  consists  in  anchoring  the 
•sigmoid  flexure  to  the  anterior  abdominal  wall  offers  a  very  effectual 
method  of  treatment  for  those  cases  that  resist  less  radical  measures. 

An  incision  about  three  inches  long  and  corresponding  to  the 
middle  of  the  left  rectus  muscle  is  made.  The  incision  crosses  the 
line  drawn  from  the  anterior  superior  iliac  spine  to  the  umbilicus. 
The  incision  penetrates  through  the  skin  and  fat  and  through  the 
aponeurosis  of  the  external  oblique  (anterior  layer  of  the  sheath  of 
the  rectus),  exposing  the  fibers  of  the  muscle.  The  fibers  of  the 
Tectus  are  split  bluntly  with  the  fingers.  The  transversalis  fascia 
(posterior  layer  of  the  sheath  of  the  rectus)  is  incised.  The  deep 
epigastric  artery  and  vein  are  encountered,  passing  obliquely  across 
the  bottom  of  the  incision.  These  vessels  are  drawn  to  one  side  or 
^re  ligated  double  and  cut  between  the  ligatures.  The  peritoneal 
layer  is  incised.  The  sigmoid  flexure  is  secured  and  drawn  up  into 
the  incision,  quite  taut,  so  as  to  draw  up  the  slack.  Care  must  be 
-exercised  not  to  twist  the  sigmoid  as  it  is  drawn  up  into  the  abdominal 
incision.  Four  or  five  sutures  of  chromic  catgut  are  introduced  in 
the  wall  of  the  bowel.  These  sutures  each  take  several  good,  broad 
bites  in  the  wall  of  the  bowel,  but  they  should  not  penetrate  into  the 
lumen  of  the  bowel.  The  sutures  are  placed  so  as  to  include  the 
strong  longitudinal  stria,  and  are  placed  about  one-half  inch  apart. 
The  ends  of  the  sutures  are  left  quite  long.  The  bowel  is  then 
replaced  in  the  abdominal  cavity  and  the  ends  of  the  sutures,  each 
threaded  in  a  large,  curved  needle  and  carried  through  the  corre- 
sponding edges  of  the  peritoneum  and  transversalis  fascia  (posterior 
layer  of  the  sheath  of  the  rectus) .  The  sutures  are  left  untied  until 
they  have  all  been  introduced.  When  the  sutures  are  tied  they  have 
the  effect  of  securing  the  wall  of  the  sigmoid  against  the  peritoneum 
and  at  the  same  time  they  close  the  incision  by  drawing  the  edges  of 
the  peritoneum  and  transversalis  fascia  together.  The  edges  of  the 
split  rectus  are  approximated  with  several  sutures  of  plain  catgut. 
The  edges  of  the  aponeurosis  of  the  external  oblique  are  sutured  with 
a  continuous  suture  of  chromic  catgut  and  the  skin  finally  closed 
with  an  intracuticular  suture  of  plain  catgut. 

In  cases  of  prolapse  of  the  rectum  the  mesosigmoid  is  unusually 
long.  This  operation  pulls  the  sigmoid  and  the  rectum  up  taut  and 
anchors  the  bowel  to  the  anterior  abdominal  wall. 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM. 


561 


Fig.  250. — Sigmoidopexy.  The  anchor  sutures  which  secure  the  wall  of  the 
sigmoid  have  been  carried  through  the  edges  of  the  peritoneum  and  transversalls 
fascia. 


562  EECTUM. 

The  writer  has  used  this  plan  in  a  considerable  number  of  cases 
of  long  standing,  intractable  prolapse,  in  both  children  and  adults, 
with  uniform  satisfactory  results,  and  with  no  recurrences. 

Resection  and  Amputation  of  the  Rectum. — Eesection  of  the 
rectum  consists  in  cutting  away  a  portion  of  the  rectal  tube  in  con- 
tinuity. The  operation  is  usually  done  for  malignant  disease; 
sometimes  for  syphilitic  and  tubercular  disease,  chronic  ulceration, 
stricture,  etc.,  where  the  disease  is  limited  to  the  upper  part  of  the 
rectum  (the  ampulla  part),  the  anal  portion  not  being  involved  in 
the  disease.  After  the  diseased  part  has  been  resected  the  upper  end 
of  the  rectum  is  brought  down  and  sutured  to  the  lower,  anal  portion. 
In  this  operation  the  sphincter  apparatus  is  not  interfered  with. 
Cases  where  this  procedure  (restriction  of  an  annular  segment  and 
reunion  of  the  two  ends  of  the  rectum)  is  applicable  are  of  rather 
rare  occurrence. 

Amputation  of  the  rectum  consists  in  removal  of  the  lower  part 
of  the  rectum,  including  the  anal  portion,  or  of  the  entire  rectum. 
If  the  entire  rectum  is  excised  the  operation  may  be  described  as 
extirpation  of  the  rectum  or  excision  of  the  rectum.  Amputation 
of  the  rectum  is  done  for  carcinoma,  extensive  ulcerations,  stricture. 

The  upper  end  of  the  bowel  may  be  drawn  down  and  sutured 
to  the  margin  of  the  skin  at  the  original  site  of  the  anus  or  an 
artificial  anus  may  be  established  in  the  left  iliac  region.  In  all 
cases  where  it  has  been  possible  to  preserve  the  sphincter  apparatus, 
external  sphincter  muscle,  the  boAvel  may  be  brought  down  and  sutured 
to  the  edges  of  the  skin  about  the  anus,  with  the  expectation  of 
obtaining  a  fairly  continent  anus.  If  it  has  been  necessary  to 
sacrifice  the  sphincter  apparatus,  however,  it  will  be  better  to 
establish  an  artificial  anus  in  the  left  iliac,  region.  A  controllable 
artificial  anus  in  this  region  is  infinitely  preferable  to  a  faecal  orifice 
in  the  original  anal  region  over  which  there  is  little  or  no  control. 

The  various  methods  of  resecting  or  amputating  the  rectum, 
entire  or  in  part,  may  be  considered  under  three  heads :  the  perineal 
the  sacral,  and  the  combined  methods. 

A  single  plan  of  operating  will  not  apply  to  all  cases.  The 
method  must  be  adapted,  and  if  necessary  modified,  to  meet  the 
requirements  of  each  individual  case.  The  indications  call  for  a  plan 
of  operation  by  which  the  disease  can  be  completely  eradicated  and 
which  will  provide  a  controllable  anal  orifice  either  in  the  origina:l  site 
of  the  anus  or  in  the  left  iliac  region. 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM.  563 

In  those  cases  where  the  tumor  is  within  reach  of  the  examining 
finger,  in  the  anal  region  or  in  the  lower  part  of  the  first  portion 
(ampulla)  of  the  rectum,  the  perineal  route  will  be  found  most  con- 
venient for  amputation,  and  the  sacral  route  most  convenient  for 
resection  and  subsequent  end-to-end  anastomosis.  AVhere  the  tumor 
is  situated  high  up,  in  the  upper  part  of  the  first  portion  of  the 
rectum,  or  where  it  involves  the  sigmoid  flexure  (pelvic  colon),  the 
combined  method  will  be  found  to  be  the  most  satisfactory  and, 
furthermore,  has  the  advantage  of  permitting  more  accurate  ex- 
amination of  the  rectum  and  the  adjacent  structures;  of  the  lymph- 
glands  behind  the  rectum,  of  the  liver,  etc.  In  those  cases  where 
the  anal  portion  is  involved  in  the  disease  and  the  sphincter  ap- 
paratus must  be  sacrificed,  the  combined  method  of  operation  with 
the  establishment  of  an  artificial  anus  in  the  left  iliac  region  will 
give  the  most  satisfactory  results. 

Prepaeation  of  the  Patient. — It  is  necessary  that  the  bowels 
be  thoroughly  emptied  before  proceeding  with  any  operation  upon 
the  rectum,  and  this  is  especially  desirable  if  the  operation  involves 
resection  or  excision  of  a  part  or  all  of  the  rectum.  A  period  of 
several  days  to  a  week  should  be  devoted  to  the  proper  preparation 
of  the  patient  for  the  operation.  During  several  days  or  the  week 
preceding  the  operation  the  bowels  are  thoroughly  emptied  by  repeated 
doses  of  cathartics,  but  during  the  twenty-four  hours  immediately 
prior  to  the  operation  no  laxatives  should  be  administered.  The 
rectum  is  irrigated  daily  with  salt  solution.  The  diet  during  the 
last  day  or  two  before  operation  should  be  limited  to  substances  which 
leave  little  or  no  residue  in  the  bowel — eggs,  broths,  albumin  water, 
etc.,  but  no  milk.  During  the  last  twenty-four  hours  preceding  the 
operation  repeated  doses  of  bismuth  and  tincture  of  opium  should 
be  given  to  set  the  bowel  at  rest.  One-half  liOur  before  operation  a 
hypodermic  dose  of  one-quarter  grain  of  morphine  is  administered. 

If  the  constriction  caused  by  the  growth  is  so  tight  that  difficulty 
is  experienced  in  emptying  the  bowel  by  laxatives,  then  it  will  be 
necessary  to  establish  an  artificial  anus,  usually  in  the  left  iliac  region. 
This  should  be  done  one  or  two  weeks  before  the  operation  upon  the 
rectum  is  undertaken.  At  the  same  time  that  the  colostomy  is  made 
the  operator  is  able  to  investigate  the  condition  of  the  rectum  through 
the  abdominal  incision;  whether  the  rectum  is  movable  or  adherent, 
the  presence  of  affected  lymph-glands,  secondary  deposits  in  the  liver, 
etc.     If  it  is  intended  to  resect  the  diseased  portion  of  the  rectum 


564  RECTUM. 

and  to  draw  the  end  of  the  bowel  down  and  suture  it  to  the  anal 
portion  or  to  the  margin  of  the  anus,  then  the  transverse  colon 
should  be  used  for  the  colostomy  because,  if  the  sigmoid  is  used,  it 
ma}^  be  difficult  or  impossible  to  draw  the  end  of  the  bowel  down 
at  the  time  of  the  operation  upon  the  rectum. 

After  resection  or  amputation  of  the  rectum  the  bowels  are  not 
permitted  to  move  for  five  of  six  days,  and  during  this  period  the 
diet  is  restricted  to  eggs,  broths,  albumin  water,  etc.,  but  no  milk, 
so  that  there  will  be  little  or  no  solid  residue  in  the  bowel.  Castor 
oil  given  in  the  evening  is  a  satisfactory  laxative  when  the  time  comes 
to  move  the  bowels. 

Perinieal  Method. — Working  from  the  perineum  we  may  resect 
a  part  of  the  rectum  and  afterward  reunite  the  ends  of  the  bowel, — 
rescctio  recti;  or  a  part  of  the  rectum  or  the  entire  rectum  may  be 
amputated, — amputatio  recti, — ^and  the  upper  end  of  the  bowel 
brought  down  and  sutured  to  the  margin  of  the  anus.  If  it  has  been 
possible  to  preserve  the  external  sphincter  we  will  have  more  or  less 
complete  control  of  the  bowel.  If  it  has  been  necessary  to  sacrifice 
the  external  sphincter,  there  will  be  no  control  over  the  bowel,  and 
under  these  circumstances  the  faecal  opening  will  be  located  in  a  very 
inconvenient  situation.  It  would  seem  to  be  better,  in  all  cases  where 
it  is  necessary  to  sacrifice  the  sphincter  apparatus,  to  establish  an 
artificial  anus  in  the  left  iliac  region,  which  will  usually  be  quite 
continent. 

Eesection"  op  the  Eectum  iisr  Continuity  (Diepeenbach). — 
This  operation  may  be  performed  for  excision  of  cicatricial  stricture 
or  for  a  malignant  growth  involving  a  limited  part  of  the  wall  of 
the  rectum  above  the  anal  portion,  the  lower,  anal  portion  being  free 
from  the  disease.  The  diseased  part  of  the  rectum  is  resected  in  its 
continuity,  an  annular  segment  of  the  rectum  corresponding  to  the 
diseased  area  excised,  and  the  lower  end  of  the  upper  portion  then 
brought  down  and  sutured  to  the  healthy  lower  anal  part.  A  great 
disadvantage  in  this  method  of  operation  is  that  the  work  is  done 
from  within  the  rectum,  and  the  wound  and  often  the  peritoneal 
cavity  must  almost  necessarily  become  infected.  It  would  appear  that 
the  sacral  method  (Kraske)  would  be  the  preferable  one  for  resecting 
a  part  of  the  rectum  in  continuity. 

The  patient  is  placed  in  the  lithotomy  position  with  the  buttocks 
raised  high  upon  a  sandbag  placed  underneath  them. 

The  sphincter  is   thoroughly   dilated  and  the   rectum  irrigated 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM.  565 

with  salt  solution.  The  anal  portion  of  the  rectum  is  divided  by  two 
incisions,  one  of  which,  commencing  within  the  anus,  passes  back- 
ward, dividing  the  anus  and  the  lower  part  of  the  rectum  as  far  back 
as  the  coccyx.  The  second  incision  commences  within  the  anus  and 
passes  forward,  dividing  the  anus  and  the  lower  part  of  the  rectum 
as  far  forward  as  the  bulb  of  the  urethra  in  the  male  and  the  posterior 
wall  of  the  vagina  in  the  female.  Two  broad,  blunt-pronged  re- 
tractors are  introduced,  one  on  either  side,  and  the  wound  thus  held 
wide  open, 

A  transverse  incision  is  made  in  either  side  of  the  rectal  wall 
just  below  the  lower  limits  of  the  disease.  These  incisions  pass 
through  the  entire  thickness  of  the  wall  of  the  rectum  and  divide 
the  lower,  healthy  anal  portion  of  the  rectum  from  the  upper  dis- 
eased part.  A  strip  of  gauze  is  inserted  into  the  upper  diseased  part 
of  the  rectum  to  prevent  its  contents  from  escaping  and  soiling  the 
wound.  The  edge  of  the  upper  diseased  part  of  the  rectum  is 
loosened  all  around  and  secured  with  a  volsella  forceps  or  with  several 
heav}'  silk  sutures  which  close  the  end  of  the  bowel  and  at  the  same 
time  serve  as  tractors.  The  diseased  portion  of  the  rectum  is  de- 
tached from  the  loose  connective  tissue  which  surrounds  it.  Making 
steady  traction,  the  diseased  part  of  the  bowel  is  drawn  down  more 
and  more  and  its  separation  from  the  surrounding  connective  tissue 
continued  until  it  is  entirely  free  on  all  sides.  We  are  then  able  to 
pull  down  the  end  of  the  bowel  and  reach  well  beyond  the  upper  limits 
of  the  disease,  at  least  two  inches  above  the  upper  limits  of  the 
disease.  The  separation  of  the  diseased  part  of  the  rectum  is  ac- 
complished chiefly  by  blunt  dissection  with  the  finger  or  the  end  of 
the  blunt-pointed  scissors,  removing  most  of  the  loose  tissue  behind 
the  rectum  at  the  same  time.  Vessels  are  clamped  as  they  are  cut 
during  the  course  of  the  operation.  All  vessels  that  have  been 
clamped  are  ligated. 

In  liberating  the  rectum  anteriorly  we  meet  the  fold  of  peri- 
toneum which  is  reflected  downward  upon  its  front  aspect.  If  this 
is  not  involved  in  the  disease  it  can  usually  be  peeled  away  from  the 
front  wall  of  the  rectum  with  the  finger  without  opening  into  it. 
If  diseased,  or  if  it  cannot  be  separated  from  the  front  wall  of  the 
rectum,  we  may  cut  through  it  close  to  the  wall  of  the  rectum,  and, 
introducing  the  finger  into  the  opening  thus  made,  draw  the  rectum 
down.  A  gauze  pad  is  temporarily  introduced  to  prevent  the  prolapse 
of  intestine  through  the  opening  and  to  protect  the  peritoneal  cavity. 


566  RECTUM. 

After  the  rectum  has  been  drawn  down  for  a  sufficient  distance  the 
opening  in  tlie  peritoneum  may  be  closed  by  suturing  its  edge  with 
catgut  to  the  peritoneal  layer  that  covers  the  anterior  wall  of  the 
rectum  or  the  opening  may  be  left  unsutured  and  a  strip  of  gauze 
introduced  into  the  pertioneal  cavity  for  the  purpose  of  drainage. 
The  end  of  the  gauze  drain  is  left  protruding  through  the  wound  in 
the  perineum^  in  front  of  the  anus.  The  upper  part  of  the  rectum, 
the  part  above  the  disease,  should  not  be  separated  from  its  surround- 
ing parts  any  more  than  is  necessary  to  permit  of  its  being  drawn 
down  to  the  edge  of  the  lower  segment  of  the  bowel  without  tension, 
and  furthermore  one  should  not  work  too  close  to  the  wall  of  the 
rectum,  in  order  not  to  damage  the  blood-supply  to  such  a  degree  that 
the  nutrition  of  the  rectum  might  be  seriously  impaired. 

After  the  rectum  has  been  liberated  to  a  point  beyond  the  upper 
limits  of  the  disease  we  may  proceed  to  excise  the  diseased  por- 
tion. Before  doing  this  two  tractors  of  silk  are  passed  through  the 
whole  thickness  of  the  wall  of  the  rectum  above  the  diseased  area  in 
order  to  steady  it  after  the  diseased  segm.ent  has  been  excised.  When 
this  has  been  accomplished  the  end  of  the  healthy  bowel  is  sutured 
to  the  edge  of  the  lower  segment  (anal  portion).  This  is  done  with 
fine  silk  sutures  which  alternately  pass  through  the  whole  thickness 
of  the  bowel  and  through  the  mucous  membrane  only.  The  edges 
of  the  anterior  and  posterior  incisions  in  the  lower  segment  of  the 
rectum,  including  the  ends  of  the  sphincter,  are  then  brought  together 
in  a  similiar  manner,  and  thus  the  continuity  of  the  bowel  is  restored. 
The  incision  in  the  skin  in  front  of  the  anus  and  that  behind  the 
anus  are  only  partly  closed,  and  a  strip  of  gauze  is  packed  to  the 
bottom  of  each  incision,  as  thorough  drainage  is  imperative. 

A  soft-rubber  tube,  wrapped  around  with  gauze,  is  introduced 
well  up  into  the  upper  part  of  the  rectum  beyond  the  line  of  suture. 
This  is  to  prevent  soiling  of  the  suture  line  and  also  to  allow  the 
passage  of  gas  during  the  few  days  immediately  following  the 
operation. 

If  the  peritoneal  pouch  has  been  opened  and  packed  the  end 
of  the  gauze  strip  emerges  through  the  incision  in  the  perineum  in 
front  of  the  anus. 

Amputation  of  the  Eectum. — In  this  operation  the  anal  por- 
tion and  part  or  all  of  the  upper  part  of  the  rectum  are  excised. 
Amputation  of  the  rectum  may  be  accomplished  with  sacrifice  of 
the  entire  sphincter  apparatus, — Lisf ranc's  operation ;   or  the  external 


OPERATIOXS  UPON  THE  ANUS  AND  RECTUM.  567 

sphincter  may  be  presented,  in  which  case  we  have  a  fairly  continent 
anus. 

LiSFEAXc's  Operation. — This  operation  is  adapted  to  those 
cases  in  which  the  disease  has  already  involved  the  lower  part  of  the 
rectnm,  the  anal  portion,  and  where  the  lower  end  of  the  bowel 
(sphincter)  cannot  be  saved.  The  operation  consists  in  cutting  well 
beyond  the  anal  margin,  removing  the  anal  portion  and  all  the  con- 
nective tissue  in  both  ischio-rectal  fossae  and  the  rectal  tube  well  up 
beyond  the  site  of  the  disease — at  least  two  inches  above  the  apparent 
upper  limit  of  the  disease.  The  end  of  the  bowel  is  then  brought 
down  and  sutured  to  the  margin  of  the  skin  about  the  anus.  In  this 
operation  the  entire  sphincter  apparatus  is  sacrificed ;  hence  the  result 
is  very  unsatisfactory  in  that  there  is  little  or  no  control  over  the 
artificial  anus  which  is  established  at  the  site  of  the  original  anus. 

The  patient  is  placed  in  the  lithotomy  position  with  the  buttocks 
raised  high  upon  a  sandbag  placed  underneath  them.  The  rectum  is 
loosely  packed  with  strip  gauze  to  prevent  leakage  and  to  help  identify 
it  during  the  course  of  the  operation.  The  anus  is  closed  with  several 
silk  sutures,  which  are  left  long  to  serve  as  tractors. 

An  incision  which  encircles  the  anus  is  made  through  the  skin. 
This  incision  is  carried  down  into  the  loose  connective  tissue  about 
the  lower  end  of  the  rectum,  and,  when  this  part  of  the  bowel  has 
been  liberated  all  around,  it  is  seized  and  drawn  down.  The  levatores 
ani,  which  are  inserted  into  the  sides  of  the  lower  part  of  the  rectum, 
are  encountered.  The  finger  is  hooked  under  the  levatores  and  they 
are  divided  with  the  scissors  close  to  the  wall  of  the  rectum,  and  then, 
gradually  working  deeper  and  deeper,  the  rectum  is  thoroughly  sep- 
arated all  around  from  the  loose  connective  tissue  which  surrounds 
it  and  is  pulled  down  more  and  more  as  this  step  of  the  operation 
progi'esses.  The  isolation  of  the  rectum  is  accomplished  chiefly  by 
dissecting  with  the  fingers  or  with  blunt-pointed  scissors. 

If  more  space  is  required,  accessory  incisions  may  be  added.  A 
posterior  incision  which  reaches  from  the  circular  incision  that  sur- 
rounds the  anus  backward  to  the  tip  of  the  coccyx  may  be  made. 
This  incision  may  still  farther  be  extended  upward  upon  the  back 
of  the  coccyx,  and,  if  necessary,  this  bone  may  be  enucleated,  after 
the  soft  parts  which  cover  it  have  been  separated  with  a  periosteum 
elevator.  An  anterior  incision  may  also  be  added.  This  incision 
passes  forward  from  the  circular  incision  which  surrounds  the  anus, 
as  far  as  the  bulb  of  the  urethra  in  the  male  and  the  posterior  wall 


568  RECTUM. 

of  the  vagina  in  the  female.  This  anterior  incision  not  only  provides 
more  room,  bnt  allows  the  operator  to  keep  himself  informed  of  the 
location  of  the  urethra  and  vagina  and  may  thus  diminish  the  liability 
of  injuring  these  parts. 

In  isolating  the  rectum  in  the  female  it  will  be  necessary  to 
separate  it  upon  its  anterior  aspect  from  the  posterior  wall  of  the 
vagina.  The  vagina  may  also  be  involved  in  the  disease,  and  it  will 
then  be  necessary  to  excise  a  part  of  its  wall  together  with  the 
rectum.  In  the  male  the  rectum  has  to  be  separated  anteriorly  from 
the  deep  urethra  and  the  prostate  gland  and  from  the  base  of  the 
bladder. 

As  we  continue  with  the  isolation  of  the  rectum  upon  its  anterior 
aspect  we  meet  the  fold  of  peritoneum  which  dips  down  in  front  of 
the  rectum:  in  the  female  between  the  rectum  and  the  vagina,  in 
the  male  between  the  rectum  and  the  bladder.  If  this  fold  .of  peri- 
toneum is  not  involved  in  the  disease,  it  may  be  peeled  away  from 
the  front  wall  of  the  rectum  without  opening  into  it.  At  times, 
however,  it  is  opened,  either  intentionally  when  it  is  diseased  or 
accidentally.  This  is  of  no  special  significance,  especially  if  the 
rectum  itself  has  not  been  opened.  The  opening  in  the  peritoneum 
may  be  closed  by  suturing  its  edge  to  the  peritoneal  layer  that  covers 
the  front  wall  of  the  rectum  with  several  catgut  stiches;  or  it  may 
be  left  unsutured  and  the  peritoneal  cavity  packed  with  gauze.  In 
separating  the  rectum  posteriorly  there  may  be  considerable  hemor- 
rhage. Blood-vessels  that  pass  to  and  from  the  rectum  and  ramify 
upon  the  lateral  walls  of  the  rectum,  branches  of  the  superior  and 
middle  hemorrhoidals,  must  be  secured  with  artery  clamps  and  ligated. 
Diseased  lymph-nodes  which  are  found  situated  behind  the  rectum 
must  also  be  enucleated. 

After  the  rectum  has  been  separated  beyond  the  upper  limits 
of  the  disease  the  whole  tube  is  pulled  down  and  the  lower  diseased 
portion  is  amputated,  making  a  straight  cut  across  the  bowel.  After 
this  has  been  done  the  edge  of  the  bowel  is  sewed  to  the  edges  of 
the  skin  around  the  anus  with  alternating  superficial  and  deep  stitches 
of  silk. 

If  there  have  been  made  accessory  posterior  and  anterior  in- 
cisions, these  may  be  closed  with  several  interrupted  sutures.  These 
sutures  must  not  be  placed  too  close  together,  as  there  should  be 
sufficient  space  between  the  sutures  to  allow  free  drainage  from  the 
parts  about  the  rectum. 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM. 


569 


Drainage  is  made  with  strips  of  gauze,  which  are  packed  loosely 
into  the  incision,  both  in  front  and  behind  the  rectum.  The  strip 
of  gauze  behind  the  rectum  should  reach  well  up  into  the  connective- 
tissue  space  between  the  sacrum  and  rectum. 

Amputation  of  the  Eectum  With  Preservation  of  the 
External  Sphincter. — ^This  operation  is  adapted  to  those  cases 
where  the  growth  is  situated  in  the  upper  part  of  the  rectum  and 
the  anal  portion  is  not  involved.  If  the  external  sphincter  muscle 
can  be  preserved  we  are  able  to  make  a  new  anus  which  is  fairly  well 
under  control. 


Fig.  251. — Resection  of  the  Rectum  (Quaiu).  Shows  incision  encircling  the 
anus  and  extending  forward  into  the  perineum  and  backward  to  the  tip  of  the 
coccyx.  The  incision  around  the  anus  is  made  very  close  to  the  anal  margin 
in  order  to  preserve  the  external  sphincter. 


The  patient  is  placed  in  the  lithotomy  position  with  the  but- 
tocks raised  high  upon  a  sandbag  which  is  placed  under  them.  The 
anus  is  stretched  and  the  rectum  irrigated  and  then  packed  with 
istrip  gauze. 

A  circular  incision  is  made  in  the  skin  entirely  around  and 
close  to  the  anus.  The  lower  end  of  the  rectum  is  dissected  loose 
from  within  the  external  sphincter,  all  around,  so  that  it  can  be 
pulled  down  and  out  of  the  anal  orifice  for  a  short  distance, — about 
an  inch.  In  this  way  the  external  sphincter  is  left  uninjured.  The 
lower  end  of  the  rectal  tube  which  has  thus  been  dissected  loose  from 
within  the  anal  margin  is  closed  with  several  silk  sutures  which  are 


570 


RECTUM. 


left  long  to  serve  as  tractors.  Gloves  which  have  been  used  for  this 
part  of  the  operation  are  discarded.  The  parts  about  the  anus  are 
again  thoroughly  cleansed  and  the  operator  proceeds  to  resect  the 
rectum  as  a  closed  tube. 

An  incision  is  made  from  the  anterior  part  of  the  incision  that 
encircles  the  anus^  forward,  through  the  anterior  part  of  the  external 
sphincter  as  far  as  the  bulb  of  the  urethra  and  another  incision  back- 
ward through  the  posterior  end  of  the  external  sphincter,  in  the 
middle  line,  as  far  as  the  tip  of  the  coccyx,  and  then  continued  farther 
backward  upon  the  coccyx  to  the  base  of  this  bone.     The  coccyx  is 


Fig.  252.— Amputation  of  the  Rectum  (Quenu).  The  coccyx  has  been  enu- 
cleated and  the  rectum  detached  and  pulled  over  toward  the  left.  The  right 
levator  ani  has  been  partly  cut  through.  The  bulb  of  the  urethra  is  exposed  in 
the  anterior  part  of  the  incision.  B.,  bulb  of  the  urethra;  L.A.,  the  levatores 
ani  muscles;  S.,  lower  edge  of  sacrum;  the  coccyx  has  been  enucleated. 


•enucleated  after  detaching  the  soft  parts  with  the  periosteum 
elevator.  The  external  sphincter  is  thus  divided  into  its  two  halves 
and  left,  one-half  in  each  edge  of  the  skin  incision.  The  space  behind 
the  rectum  is  entered  and  the  rectum  and  the  loose  connective  tissue, 
lymph-nodes,  etc.,  that  lie  behind  it  all  detached  in  one  mass  from 
the  front  of  the  sacrum ;  the  levatore  ani  of  either  side  is  hooked  down 
with  the  finger  and  divided  with  the  scissors.  The  rectum  is  sepa- 
rated, anteriorly,  from  the  deep  urethra,  prostate  gland,  seminal 
vesicles,  base  of  bladder  in  the  male,  and  from  the  posterior  wall  of 
the  vagina  in  the  female.  In  the  male  a  catheter  in  the  urethra  will 
indicate  the  position  of  the  urethra  and  protect  it  from  injury. 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM. 


571 


After  the  levatores  ani  have  been  cut  and  the  rectum  separated 
anteriorly  it  may  be  drawn  down  sufficiently  to  show  the  peritoneal 
fold  which  is  reflected  upon  its  front  surface.  This  fold  is  incised 
close  to  the  wall  of  the  rectum,  first  around  one  side  and  then 
around  the  other.  The  peritoneal  cavity  which  has  been  thus  opened 
is  packed  temporarily  with  gauze.  The  rectum  may  be  dra\vn  down 
out  of  the  incision  for  a  distance  of  four  or  five  inches.  The  effort 
to  pull  the  rectum  down  still  farther  out  of  the  incision  is  resisted 
by  the  folds  of  peritoneum  that  pass  from  the  upper  part  of  the 
rectum  back  to  the  sacrum,  and  which  correspond   to  the  folds  of 


Fig.  253. — Amputation  of  the  Rectum  (Queuu).  The  levatores  ani  have  been 
divided  and  the  rectum  drawn  down  still  farther  out  of  the  incision.  The  bulb 
of  the  urethra,  the  posterior  surface  of  the  prostate  and  the  recto-vesical  fold 
of  peritoneum  are  exposed.  B.,  bulb  of  the  urethra;  L.A.,  levator  ani  muscle; 
P.,  recto-vesical  fold  of  peritoneum;  PR.,  prostate  gland. 

peritoneum  that  form  the  mesosigmoid  (pelvic  colon).  The  superior 
hemorrhoidal  artery  descends  between  these  folds  to  reach  the  rectum. 
A  clamp  is  applied  to  the  peritoneal  fold,  close  up  to  the  sacrum, 
and  the  fold  divided  in  front  of  the  clamp,  between  the  clamp  and 
the  rectum.  The  clamp  has  the  superior  hemorrhoidal  vessels  in  its 
grasp.  The  rectum  may  now  be  pulled  down  freely  out  of  the 
incision.  The  rectum  is  drawn  out  until  a  portion  of  the  sigmoid 
flexure,  well  above  the  disease,  can  be  brought  down  into  the  anal 
margin  without  tension.  Occasionally  the  mesosigmoid  is  quite  short 
and  resists  the  effort  to-  pull  down  the  end  of  the  bowel,  and  it  may 
then  be  necessary  to  still  further  clamp  and  divide  the  mesosigmoid 


672 


RECTUM. 


before  the  desired  part  of  the  rectum  can  be  brought  down  without 
tension.  In  making  the  additional  incision  into  the  mesosigmoid 
the  cut  should  be  made  as  close  as  possible  to  its  root  (line  of  attach- 
ment to  the  sacrum)  in  order  to  avoid  injuring  the  terminal  branches 
of  the  sigmoid  arteries  which  are  necessary  for  the  supply  of  the 
bowel. 

All  vessels  that  have  been  clamped  are  ligated  and  the  edge  of 
the  peritoneal  fold  which  was  cut  away  from  the  front  of  the  rectum 


Fig.  254.— Amputation  of  the  Rectum  (Quenu).  The  recto-vesical  fold  of 
peritoneum  has  been  incised  and  the  bowel  drawn  down,  far  out  of  the  inci- 
sion, so  that  the  sigmoid  flexure  presents  in  the  incision.  B.,  bulb  of  the  urethra; 
P.P.,  edges  of  the  recto-vesical  fold  of  peritoneum;  PR.,  prostate  gland;  8., 
sigmoid  flexure. 

is  sutured  with  plain  catgut  stitches  to  the  front  and  sides  of  the 
bowel — sigmoid  flexure,  thus  closing  the  peritoneal  cavity.  The 
incisions  in  the  perineum  are  closed  with  interrupted  silk  stitches 
and  the  anterior  and  posterior  ends  of  the  external  sphincter  care- 
fully and  accurately  sutured  together.  The  lower,  diseased  part  of 
the  bowel  is  amputated,  and  the  end  of  the  sigmoid  sutured  to  the 
edges  of  the  anal  margin,  all  around,  with  silk  sutures  placed  quite 
close  together,  spaces  of  one-half  inch  between  them. 

A  rubber  tube  wrapped  around  with  gauze  is  introduced  into 


OPERATIONS  UPON  THE  AXUS  AND  RECTUM. 


573 


the  rectum  to  permit  the  escape  of  gas,  etc.  A  gauze  strip  is  packed 
into  the  posterior  part  of  the  perineal  incision,  behind  the  anal 
opening,  and  reaching  well  up  into  the  space  between  the  rectum  in 
front  and  the  sacrum  behind,  in  order  to  insure  good  drainage  of 
this  space.  A  second  drainage  strip  is  inserted  into  the  anterior 
part  of  the  incision,  in  front  of  the  anus. 

Vaginal  Method. — Access  to  the  rectum  may  be  obtained 
through  an  incision  in  the  posterior  wall  of  the  vagina.  After  the 
rectum  has  been  exposed  it  is  detached  in  the  manner  described  in 
the  preceding  operations, — "perineal  method."    After  the  rectum  has 


Fig.  255. — Amputation  of  the  Rectum  (Quenu).  The  rectum  has  been  ampu- 
tated and  the  lower  edge  of  the  sigmoid  sutured  to  the  edges  of  the  anal  incision. 
Gauze  drains  emerge  from  the  incisions  in  front  of  and  behind  the  anus.  T,  a 
rubber  tube  wrapped  around  with  gauze,  which  is  introduced  into  the  rectum 
to  permit  the  escape  of  gas,  etc. 

been  resected  or  amputated  the  incision  in  the  vaginal  wall  is  closed 
by  suture. 

Sacral  Route  (Kraske). — The  rectum  is  approached  through  an 
incision  in  the  sacro-coccygeal  region  after  the  coccyx  and  usually 
a  portion  of  the  sacrum  have  been  removed.  This  plan  of  operation 
is  well  adapted  to  resection  of  a  portion  of  the  rectum,  where  the 
disease  is  limited  to  the  upper  part  of  the  rectum  and  the  anal  por- 
tion is  healthy.  It  affords  good  access  to  the  upper  diseased  part  of 
the  bowel.  Through  this  route  the  diseased  portion  may  be  resected 
and  the  upper  end  of  the  bowel  brought  down  and  sutured  to  the 
lower,  anal,  end;  or  the  rectum,  including  the  anal  portion,  may  be 
amputated  and  an  artificial  anus  established  in  the  upper  corner  of 


574 


RECTUM. 


the  incision.  The  perineal  or  the  combined  method  will  be  found 
more  satisfactory,  however,  in  those  cases  where  amputation,  rather 
than  resection,  of  the  rectum  is  to  be  performed. 

Eesection  op  the  Rectum  in  Continuity. — The  operation  is 
adapted  to  these  cases  where  the  disease  is  limited  to  a  circumscribed 
part  oi  the  bowel  and  the  anal  portion  is  not  involved. 

The  operation  is  described  in  three  steps : — 

1.  Sacral  "Vor  operation":  resection  of  the  coccyx  and  part  of 
the  sacrum. 


Fig.  256.— Resection  of  the  Rectum  (Eraske).  The  patient  lies  upon  the  left 
side.  The  incision  is  indicated  by  the  solid  line.  It  reaches  from  the  posterior 
inferior  iliac  spine  to  the  tip  of  the  coccyx.  The  coccyx  is  enucleated  and  the 
lower  portion  of  the  sacrum  resected  as  indicated  by  the  dotted  lines  according 
to  the  amount  of  space  required. 


2.  Resection  of  the  diseased  portion  of  the  bowel. 

3.  Apposition  of  the  ends  of  the  bowel  and  treatment  of  the 
incision,  etc. 

Sacral  "Yor  Operation." — The  patient  lies  upon  the  left  side 
(Hochenegg),  with  the  belly  inclined  somewhat  toward  the  table,  the 
lower  limbs  strongly  flexed  at  the  Imees  and  hips  and  supported  thus 
by  an  assistant;  or  he  may  lie  upon  the  abdomen  with  the  pelvis 
raised  high  upon  a  sandbag  placed  underneath. 

A  slightly  curved  incision  with  the  concavity  toward  the  left  is 
made.     The  incision  begins  upon  a  level  with  the  posterior  inferior 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM. 


575 


iliac  spine,  about  level  with  the  middle  of  the  sacrum  and  about  two 
inches  to  the  left  of  the  middle  line.  It  is  carried  down  to  the  middle 
of  the  upper  border  of  the  coccyx,  and  from  this  point  it  is  continued 
down  in  the  middle  line  upon  the  coccyx,  ending  at  its  tip.  This 
incision  divides  the  skin,  subcutaneous  fat,  and  superficial  fascia,  and 
exposes  in  the  upper  part  of  the  wound  the  lower  portion  of  the 
gluteus  maximus  muscle,  the  fibers  of  which  run  at  right  angles  to 
the  line  of  the  incision.  That  part  of  the  gluteus  maximus  which 
presents  itself  in  the  wound  is  incised  and  retracted  when  the  line 
of  attachment  of  the  greater  and  lesser  sacro-sciatic  ligaments  to  the 


Fig.  257. — Back  Part  of  Ilium  and  Sacrum.  Coccyx  removed.  A,  A,  usual 
line  of  section  through  sacrum;  A,  B,  line  of  section  to  remove  all  of  lower 
part  of  sacrum;  81,  lower  end  of  sacro-iliac  articulation;  1,  2,  3,  4,  poste- 
rior sacral  foramina. 


sacrum  is  exposed.     These  structures  are  also  divided  close  to  the 
edge  of  the  sacrum. 

Penetrating  through  the  fat  in  the  ischio-rectal  fossa  the  coccy- 
geus  vrhich  is  attached  to  the  border  of  the  coccyx  and  sacrum,  and 
the  levator  ani  which  is  attached  to  the  coccyx  near  its  tip,  are  ex- 
posed. These  muscles  are  covered  over  by  a  thin  fascia — the  anal; 
they  are  divided  with  the  knife  close  to  the  edge  of  the  sacrum  and 
coccyx.  The  soft  parts  are  separated  with  a  periosteum  elevator  from 
the  posterior  surface  of  the  coccyx  and  the  bone  then  seized  with  the 
bone  forceps  and  extirpated.  The  sphincter  ani  is  cut  away  from 
the  tip  of  the  coccyx  close  to  the  bone.  If  the  arteria  sacra  media, 
which  decends  in  front  of  the  sacrum,  is  injured,  it  may  be  clamped 
and  tied. 


576  RECTUM. 

The  levator  ani  and  coccygeus  muscles  having  been  already 
divided,  the  operator  penetrates  through  the  loose,  fatty  tissue  which 
lies  behind  the  rectum  with  the  fingers  so  as  to  expose  the  posterior 
surface  of  the  rectum.  If  this  space  is  not  sufficiently  wide  after 
extirpation  of  the  coccyx  it  will  be  necessary  to  resect  a  portion  of 
the  sacrum.  This  is  done  with  the  chisel  and  mallet.  The  soft  parts 
are  separated  from  the  lower  part  of  the  sacrum  with  the  periosteum 
elevator,  and  that  portion  of  the  sacrum  is  resected  which  lies  below 
a  curved  line  that  commences  at  the  left  border  of  the  bone,  just 
below  the  level  of  the  third  posterior  sacral  foramen,  and  which 
terminates  at  the  middle  of  the  lower  end  of  the  sacrum. 

If  necessary  to  get  still  more  room  the  line  of  section  through  the 
sacrum  may  be  carried  straight  across  the  bone  just  below  the  third 
posterior  sacral  foramina  from  the  left  to  the  right  border  of  the 
bone,  thus  removing  all  of  the  sacrum  below  the  third  sacral  foramina. 
The  guide  to  the  location  of  the  third  sacral  foramen  is  the  lower 
end  of  the  sacro-iliac  articulation.  The  lower  end  of  the  sacro-iliac 
articulation  lies  just  above  the  lower  margin  of  the  third  posterior 
sacral  foramen. 

In  making  the  resection  of  the  sacrum  it  is  unwise  to  go  above 
the  lower  border  of  the  third  posterior  sacral  foramen  on  account 
of  the  important  structures  which  emerge  from  the  first,  second,  and 
third  anterior  sacral  foramina  (sacral  plexus).  Through  the  fourth 
anterior  sacral  foramen  branches  emerge  which  are  distributed  to 
the  bladder  and  the  rectum.  If  these  branches  are  damaged  some 
disturbance  of  the  function  of  these  organs  will  follow,  but  this  is 
only  temporary,  control  being  rapidly  regained.  If  the  left  half  only 
of  the  lower  portion  of  the  sacrum  is  removed,  this  disturbance  will 
be  much  less  marked. 

EESECTIOISr    OF    THE    DISEASED   PORTION"    OF    THE   EeOTUM. The 

diseased  part  of  the  rectum  is  freed  upon  its  posterior  aspect  and 
upon  the  sides  from  the  loose  fat  and  connective  tissue  that  sur- 
round it.  It  is  then  separated  upon  its  anterior  aspect.  All  blood- 
vessels are  clamped  and  ligated  as  they  are  cut.  The  separation  of 
the  rectum  is  accomplished  with  the  finger,  and  care  must  be  taken 
not  to  open  into  the  bowel.  When  the  diseased  part  of  the  rectum 
has  been  freed  all  around,  a  heavy  silk  ligature  is  tied  tightly  around 
it  just  below  the  lower  limits  of  the  disease,  and  the  lower  part  of 
the  bowel  is  again  irrigated  and  packed  with  strip  gauze  through 
the  anus.     The  bowel  is  then  divided  below  the  ligature,  thus  cutting 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM. 


57? 


the  diseased  part  away  from  the  lower,  healthy  anal  portion.  The 
wound  is  not  soiled,  because  the  diseased  segment  is  shut  off  by  the 
ligature  which  has  been  applied  about  it,  and  the  lower  anal  segment, 
besides  having  been  thoroughly  irrigated,  is  packed  with  gauze. 

The  diseased  portion  of  the  gut  is  now  seized,  and,  while  trac- 
tion is  made,  it  is  gradually  dissected  out  of  its  bed  of  fat  and 
connective  tissue,  being  thoroughly  isolated  u])on  all  sides,  so  that  it 


Fig.  258.— Resection  of  the  Rectum  {Kraske).     The  lower  part  of  the  rectum 

is   loosened  all    around    and    drawn    out   of   the  incision.     A  ligature   is   thrown 

around    the   rectum    below    the   location    of    the    disease   and  the    bowel    divided 
below  the  ligature  as  indicated  by   the   dotted  line. 

can  be  pulled  down  as  far  as  may  be  necessary.  The  detachment  of 
the  bowel  is  accomplished  largely  by  blunt  dissection  with  the  fingers. 
Tn  freeing  the  rectum  upon  its  anterior  aspect,  the  pouch  of 
peritoneum  which  dips  do-oTi  upon  its  front  wall,  between  it  and  the 
uterus  and  vagina  in  the  female  and  the  bladder  in  the  male  is 
encountered.  It  may  be  necessary  to  open  the  pouch,  and,  indeed, 
this  is  probably  desirable  in  all  cases,  since  the  bowel  can  then  be 
brought  down  with  much  more  ease.  After  the  opening  has  been 
made  in  the  peritoneal  pouch  it  may  be  enlarged  by  cutting  with 
the   scissors,    upon   either   side,    close   to    the   wall   of   the   rectum. 

37 


578 


RECTUM. 


Through  the  opening  which  is  thus  made  two  fingers  are  introduced 
and  the  bowel  pulled  down.  After  the  bowel  has  been  pulled  down 
as  far  as  necessary  the  edge  of  the  opening  in  the  peritoneum  may 
be  sewed  to  the  peritoneal  layer  of  the  sigmoid  flexure  with  plain 
catgut  suture,  thus  closing  off  the  peritoneal  cavity;  or  else  the  peri- 
toneal pouch  may  be  left  open  and  packed  with  gauze.  If  the  peritoneal 


Fig.  259. — Resection  of  the  Rectum  (Kraslte).  The  rectum  has  been  exten- 
sively detached  and  drawn  out  of  the  incision  and  ligated  well  above  the  upper 
limits  of  the  disease.  It  is  divided  above  the  ligature  as  indicated  by  the 
dotted  line.     The  lower,   anal  portion  is  packed  with  iodoform  gauze. 

fold  is  involved  in  the  disease  it  may  be  already  obliterated  by  its 
opposing  surfaces  having  become  agglutinated,  or  the  growth  may 
have  extended  still  farther  so  as  to  involve  the  uterus  or  bladder. 
This  will  add  to  the  difficulty  of  the  operation;  but  some  surgeons 
do  not  consider  it  a  counter-indication  to  the  continuance  of  the 
operation,  because,  if  necessary,  the  parts  of  these  organs  that  are 


OPERATIONS  UrON  THE  ANUS  AND  RECTUM. 


579 


involved  may  be  resected.  If  the  peritoneal  fold  is  not  involved  in 
the  di.^ease  it  can  usually  be  peeled  away  from  the  front  wall  of  the 
rectum  with  the  finger,  and  in  this  case  the  operation  may  be  com- 
pleted without  opening  into  the  peritoneal  cavity. 

Diseased  lymph-nodes  located  behind  the  rectum,  between  it  and 
the  sacrum,  should  also  be  enucleated.  There  may  be  considerable 
bleeding  caused  by  separating  the  rectum  upon   its  posterior  aspect 


Fig.  260.— Resection  of  the  Rectum  {Kraske).     The  upper  end  of  the  bowel  is 
brought  down  and  united  by  interrupted  sutures  to  the  lower,  anal  end. 


and  sides  from  branches  of  the  superior  hemorrhoidal;    they  should 
be  clamped  and  ligated. 

After  the  bowel  has  been  detached  all  around  it  is  drawn  out 
of  the  incision  as  far  as  possible.  Just  beyond  the  upper  limits  of 
the  disease  a  heavy  silk  ligature  is  thrown  around  the  rectum  and 
tied,  and  the  contents  of  the  diseased  portion  of  the  bowel  are  thus 
confined  within  that  part  of  the  bowel  which  is  to  be  resected.  Gauze 
pads  are  placed  about  and  underneath  the  rectum  to  protect  the 
wound  from  possible  leakage  and  the  diseased  part  is  then  cut  away 
from  the  upper  healthy  portion  of  the  bowel.  Before  the  bowel  is 
divided  an  assistant  grasps  it,  beyond  the  intended  line  of  section, 
with  a  broad,  rubber-sheathed  clamp  or  with  the  fingers  so  that,  when 


580  RECTUM. 

the  diseased  part  is  cut  away,  there  will  be  no  leakage  of  the  bowel 
contents.  The  diseased  portion  having  been  thus  excised,  the  upper 
end  of  the  bowel  is  released  from  the  grasp  of  the  assistant  and 
immediately  packed  with  gauze,  and  we  are  ready  for  the  final  step 
of  the  operation, — the  anastomosis  of  the  upper  end  of  the  bowel  to 
the  lower  anal  portion. 

Anastomosis  of  the  Ends  oe  the  Bowel. — During  the  appli- 
cation of  the  sutures  that  unite  the  two  ends  of  the  bowel  care  should 
be  taken  that  no  bowel  contents  soil  the  suture  line.  The  gauze 
which  has  been  packed  into  the  upper  segment  of  the  bowel  prevents 
this.  There  should  be  no  tension  whatever  upon  the  upper  segment 
— ^no  tendency  for  it  to  draw  up  into  the  abdomen,  away  from  the 
anal  portion.  Proper  detachment  of  the  bowel  and  opening  of  the 
peritoneal  pouch  will  obviate  this. 

For  uniting  the  ends  of  the  bowel  fine-silk  sutures  are  used. 
The  suture  is  commenced  anteriorly,  in  the  middle  line,  working 
around  upon  either  side  toward  the  back.  The  sutures  should  be 
introduced  from  the  inner  surface  of  the  bowel  and  tied  so  that  the 
knots  are  within  the  lumen  of  the  bowel — they  should  be  interrupted 
and  each  should  include  the  whole  thickness  of  the  wall  of  the  gut, 
and  be  placed  about  Yq  inch  distant  from  each  other.  The  sutures 
which  are  introduced  last  and  which  join  the  two  segments  of  the 
bowel  posteriori}^,  must  be  introduced  from  the  outer  surface  and  do 
not  penetrate  the  whole  thickness  of  the  wall  of  the  bowel.  They 
simply  include  the  outer  coats.  When  these  latter  sutures  have  been 
tied,  it  will  be  found  that  the  knots  are  upon  the  outer  aspect  of  the 
bowel.  Before  completing  the  anastomosis  of  the  two  ends  of  the 
bowel  behind,  a  rubber  tube,  wrapped  around  with  gauze,  is  introduced 
through  the  anus  into  the  bowel,  well  up  beyond  the  line  of  suture. 
This  protects  the  suture  line  and  also  permits  the  escape  of  gas 
during  the  few  da3rs  immediately  following  the  operation.  A  strip 
of  gauze  is  introduced  into  the  wound  down  to  the  line  of  suture  upon 
either  side  of  the  bowel  for  the  purpose  of  providing  drainage  in  the 
event  of  leakage. 

Union  most  often  fails  in  the  posterior  part  of  the  suture  line 
in  the  bowel;  this  is  due  probably  to  the  damage  done  to  the  vessels 
which  supply  the  bowel,  in  isolating  it.  Such  a  break  of  the  suture 
line,  however,  usually  does  no  harm  if  proper  drainage  of  the  wound 
has  been  provided  and  usually  the  resulting  fgecal  fistula  closes  spon- 
taneously, or  may  be  closed  by  a  subsequent  operation. 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM.                   581 
AMrUTATION  OF  THE  EeCTUM  INCLUDING  THE  AnAL  PORTION. 

If  it  ip  desired  to  remove  the  lower  (anal)  portion  of  the  bowel,  to- 
gether with  the  rest  of  the  rectum,  the  skin  incision  shovild  be  pro- 
longed from  the  tip  of  the  coccyx,  so  as  to  encircle  the  anus.  After 
the  coccyx  and  part  of  the  sacrum  have  been  resected  as  described 
above,  the  whole  length  of  the  bowel,  including  the  anal  portion,  is 
isolated,  beginning  below  at  the  anus  and  working  upward.  Upon 
either  side,  near  the  anus,  the  attachment  of  the  levator  ani  is 
separated  from  the  rectum  with  the  scissors,  working  close  to  the 
wall  of  the  rectum.  At  times,  some  difficulty  in  separating  the 
rectum  from  the  prostate  or  the  vagina  is  experienced.  A  catheter 
is  introduced  into  the  bladder  as  a  precautionary  measure  to  indicate 
the  location  of  the  urethra.  When  the  bowel  has  been  isolated  to  a 
point  beyond  the  upper  limits  of  the  disease,  a  ligature  is  thrown 
around  the  rectum  and  the  diseased  portion  cut  away.  The  end  of 
the  proximal  (upper)  part  of  the  bowel  into  which  a  strip  of  gauze 
has  been  packed  is  then  sewed  to  the  margins  of  the  skin  in  the 
upper  part  of  the  incision  close  to  the  edge  of  the  sacrum  with  inter- 
rupted silk  sutures.  The  wound  is  then  packed  carefully  about  the 
bowel,  above  and  below,  and  the  skin  incision  partly  closed  with 
several  silk  sutures.  The  bowel  may  be  twisted  through  a  quarter  of 
a  circle  before  uniting  it  to  the  margin  of  the  skin,  with  the  idea  of 
making  the  artificial  anus  more  continent.  A  ffecal  fistula  in  this 
position  is  very  inconvenient.  Better  to  establish  an  artificial  anus 
in  the  left  iliac  region. 

In  some  cases  it  may  be  possible  to  preserve  the  external 
sphincter  muscle.  Under  these  circumstances  the  end  of  the  bowel  may 
be  drawn  down  and  sutured  to  the  edges  of  the  anal  margin  after 
the  mucous-membrane  layer  has  been  dissected  away  from  within 
the  anal  ring. 

Combined  Method  (also  Called  the  Abdomino-Perineal,  Abdomino- 
Anal,  etc.). — This  operation  is  suitable  for  cancer  involving  the  upper 
part  of  the  rectum  and  sigmoid  flexure  (pelvic  colon).  With  many 
surgeons  this  is  the  operation  of  choice  for  practically  all  cases  of 
cancer  of  the  rectum.  Up  to  the  present  the  immediate  mortality 
has  been  high,  especially  in  fat  men.  In  men  the  mortality  varies 
between  50  and  80  per  cent.;  in  women,  between  10  and  20  per 
cent.  It  is  to  be  hoped  that  these  figures  will  be  greatly  improved 
as  surgeons  become  more  familiar  with  the  operation. 

By  the  combined  method  the  diseased  portion  of  the  bowel  (pelvic 


582  RECTUM. 

colon  and  rectum)  is  detached  through  the  abdominal  incision  and 
then  removed  later  through  an  incision  in  the  perineum.  The  proxi- 
mal end  of  the  bowel  is  either  fixed  in  an  incision  in  the  abdominal 
wall  and  a  permanent  artificial  anus  thus  established;  or  else  it  is 
pulled  down  and  sutured  to  the  lower  end  of  the  rectum  (if  the 
lower  portion  has  been  left  remaining)  or  to  the  edge  of  the  original 
anal  margin. 

Combined  Operation  with  the  Establishment  of  an  Arti- 
EiciAL  Iliac  Anus. — This  operation  is  less  complicated  than  some  of 
the  others  that  may  be  practiced  by  the  combined  method.  -  It  permits 
of  very  radical  excision  of  the  diseased  parts  and  gives  an  artificial 
anus  which  is  quite  continent.  The  operation  may  be  described  in 
two  steps,  the  abdominal  and  the  perineal. 

The  Abdominal  Step. — ^The  patient  is  placed  in  the  Trendel- 
enberg  position  and  an  incision  made  in  the  middle  line  from  the 
symphysis  pubis  upward  for  a  distance  of  four  or  five  inches.  The 
liver  is  examined  to  ascertain  whether  it  is  free  from  metastatic 
growth.  In  men,  in  order  to  gain  enough  room,  it  may  be  necessary 
to  incise  the  recti  muscles  close  to  their  attachment  to  the  pubic 
bones.    This  is  to  be  avoided  if  possible. 

The  small  intestines  are  pushed  up  toward  the  diaphragm  and 
held  thus,  out  of  the  way,  by  several  gauze  pads.  The  sigmoid  fiexure 
is  secured  well  above  the  location  of  the  disease  and  followed  downward 
to  the  point  where  it  becomes  continuous  with  the  rectum,  opposite  the 
third  sacral  vertebra.  This  part  of  the  sigmoid  flexure  which  lies 
loose  in  the  pelvic  cavity  is  called  the  pelvic  colon  and  was  formerly 
described  as  the  first  part  of  the  rectum.  The  growth  is  examined, 
whether  movable  or  adherent  to  adjacent  organs.  Investigation  is  also 
made  as  to  the  degree  of  involvement  of  the  lymph-nodes  behind  the 
rectum,  and  along  the  course  of  the  internal  iliac  vessels.  It  must  also 
be  determined  whether,  after  the  diseased  part  has  been  excised,  there 
will  be  enough  of  the  sigmoid  (pelvic  colon)  remaining  to  permit  the 
end  of  the  bowel  to  be  brought  down  and  sutured  to  the  anal  portion 
of  the  rectum  or  to  the  margin  of  the  anus;  or  whether  it  would  be 
more  satisfactory  to  make  an  artificial  anus  in  the  left  iliac  region. 
It  will  be  noticed  that  there  is  ample  room  to  make  the  necessary 
investigation  in  the  female  pelvis,  whereas,  in  the  male,  and  es- 
pecially in  fat  men,  the  pelvic  cavity  is  narrow  and,  at  times,  con- 
siderable difficulty  will  be  experienced  in  exploring  the  pelvis  and 
carrying  out  the  steps  of  the  operation. 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM.        583 

If  it  is  decided  to  proceed  with  the  operation  the  sigmoid  is 
drawn  up  out  of  the  pelvis  into  the  incision,  emptied  of  its  con- 
tents by  stripping  between  the  fingers  and  surrounded  by  two  heavy 
silk  ligatures  which  are  passed  through  the  mesosigmoid  and  placed 
fairly  close  together.  The  bowel  is  divided  between  the  ligatures. 
The  end  of  each  segment  of  the  bowel  is  cleansed  and  then  inverted 
and  secured  thus  with  a  purse-string  suture  of  silk,  which  is  placed 


Fig.  261.— Blood-supply  of  the  Sigmoid  Flexure,  and  Rectum.  C.8.,  arteria 
colica  sinistra;  I.E.,  inferior  hemorrhoidal;  I.M.,  inferior  mesenteric;  M.H., 
middle  hemorrhoidal;  S.,  sigmoid  arteries;   S.H.,  superior  hemorrhoidal. 

in  the  wall  of  the  bowel  about  one  inch  beyond  the  ligatured  end.  The 
end  of  the  bowel  is  inverted,  the  purse-string  pulled  tight  and  tied. 
Both  ends  of  the  bowel  are  treated  in  this  manner.  The  ends  of  the 
purse-strings  are  left  long  to  serve  as  tractors. 

For  the  purpose  of  the  artificial  iliac  anus  an  incision  is  made 
in  the  left  iliac  region,  penetrating,  "grid-iron"  fashion,  between 
the  fibers  of  the  several  abdominal  muscles  and  the  end  of  the  upper 
segment  of  the  bowel  drawn  out  through  the  incision  for  a  distance 


684  RECTUM. 

of  three-quarters  of  an  inch  with  the  tails  of  the  purse-string  suture 
which  were  left  long  for  this  purpose.  The  end  of  the  bowel  is  fixed 
in  the  incision  by  several  sutures  of  chromic  catgut,  No.  1,  which 
secure  the  end  of  the  bowel  to  the  edges  of  the  peritoneum  and  trans- 
versalis  fascia  in  a  manner  quite  analogous  to  that  described  for 
colostomy,  page  465.  The  bowel  is  not  opened  for  twenty-four  to 
forty-eight  hours  after  the  operation,  depending  upon  the  conditions 
in  each  case — degTce  of  distention,  etc.  To  open  the  bowel  the  purse- 
string  is  cut  and  the  end  of  the  bowel  everted  and  opened. 

The  next  step  of  the  operation  is  devoted  to  the  lower  piece  of 
the  boAvel — the  portion  which  is  to  be  excised.  The  mesentery  of 
this  part  of  the  bowel  is  tied  off  with  one  or  two  ligatures  of  catgut. 
These  ligatures  are  passed  double  with  the  blunt  carrier,  so  that 
after  they  have  been  tied,  the  mesentery  may  be  cut  between  them. 
The  mesosigmoid  is  thus  treated,  using  as  many  ligatures  as  may  be 
necessary  to  tie  it  off  as  far  down  as  the  point  where  it  ceases  to 
exist — where  the  pelvic  colon  becomes  the  rectum — oj)posite  the  third 
sacral  vertebra.  The  inferior  mesenteric  vessels  are  sought  between 
the  folds  of  the  mesosigmoid,  to  the  left  of,  and  upon  a  level  with,, 
the  promontory  of  the  sacrum.  At  this  point  the  inferior  mesenteric 
artery  dips  down  into  the  pelvis  to  become  the  superior  hemorrhoidal. 
It  rests  upon  the  bifurcation  of  the  left  common  iliac  artery  and  is 
in  close  relationship  with  the  ureter.  Just  before  the  inferior  mesen- 
teric dips  into  the  pelvis  to  become  the  superior  hemorrhoidal  it  gives 
off  the  sigmoid  arteries,  usually  two  in  number,  which  are  distributed 
to  and  are  essential  for  the  nutrition  of  the  sigmoid  flexure.  In 
their  course  to  the  sigmoid  these  vessels  run  between  the  layers  of 
the  mesosigmoid,  breaking  up  mto  numerous  branches  which  com- 
municate with  each  other  and  form  a  series  of  arches  before  they 
reach  the  bowel.  Care  must  be  taken,  in  tying  the  superior  hemor- 
rhoidal, to  apply  the  ligature  below  the  point  where  the  sigmoid 
arteries  are  given  off  from  the  inferior  mesenteric. 

The  peritoneum  which  covers  the  rectum  is  incised  downward, 
along  each  side  of  the  rectum  and  below,  across  the  front  of  the 
rectum — ^where  it  is  reflected  forward  on  to  the  bladder  in  the  male 
and  on  to  the  posterior  wall  of  the  vagina  in  the  female.  The  rectum, 
including  all  the  loose  connective  tissue  and  lym-ph-nodes  that  are 
situated  behind  it,  between  it  and  the  front  surface  of  the  sacrum, 
is  peeled  out  in  one  mass.  This  is  done,  bluntly,  with  the  fingers, 
cleaning  the  parts  away  clear  back  to  the  anterior  surface  of  the 


OPERATIONS  UPON  THE  ANUS  AND  RECTUM.  585 

sacnim.  The  sacro-media  artery  is  secured  and  ligated  just  below  its 
origin  from  the  point  where  the  aorta  bifurcates,  before  beginning 
this  part  of  the  operation.  Working  downward  along  the  sides  of 
the  rectum  some  bands  of  connective  tissue,  including  the  middle 
hemorrhoidal  arteries,  are  met  with  and  may  be  clamped  before  being 
torn  or  cut  close  to  the  wall  of  the  rectum.  Below  and  anteriorly,  in 
the  male,  the  rectum  is  separated  from  the  base  of  the  bladder  and 
from  the  posterior  surface  of  the  prostate;  in  the  female  from  the 
upper  part  of  the  vagina,  uterus.  The  isolation  of  the  rectum  is 
continued  downward  as  far  as  the  attachment  of  the  levator  ani  muscle 
upon  either  side.  In  enucleating  affected  lymph-nodes,  etc.,  care 
must  be  exercised  not  to  injure  the  ureters  as  they  dip  down  into  the 
pelvis  at  the  sacro-iliac  synchondroses.  It  is  also  necessary  to  again 
avoid  the  ureters  in  separating  the  rectum  below,  from  the  base  of 
the  bladder,  as  the  ureters  pass  forward  in  this  situation  close  to  the 
sides  of  the  rectum  to  reach  the  base  of  the  bladder  and  would  be  in 
danger  of  being  injured. 

After  the  pelvic  colon  and  rectum  have  been  completely  detached 
they  are  pushed  down  into  the  bottom  of  the  pelvis  and  the  torn 
edges  of  the  pertioneum  are  brought  together  with  sutures  so  as  to 
restore  the  peritoneal  lining  of  the  floor  of  the  pelvis.  The  detached 
rectum  and  pelvic  colon  thus  lie  below  the  restored  peritoneal 
lining  of  the  pelvic  floor.  The  abdominal  part  of  the  operation  is 
thus  complete  and  the  extirpation  of  the  rectum  from  below  remains 
to  be  accomplished. 

Perineal  Step. — The  technique  of  this  part  of  the  operation 
does  not  differ  from  that  described  under  "Perineal  Method,"  "Lis- 
franc's  operation,''  page  567. 

The  patient  is  placed  in  the  lithotomy  position,  the  legs  flexed 
upon  the  abdomen  and  the  buttocks  raised  high  upon  a  sandbag  placed 
underneath  them. 

The  rectum  is  loosely  packed  with  strip  gauze  through  the  anus, 
and  the  anus  closed  with  several  silk  sutures.  An  incision  is  made 
which  encircles  the  anus  and  reaches  back  to  the  coccyx  (see 
page  567).  The  rectum  is  then  detached,  working  from  below  up- 
ward, separating  it  from  the  bulb  of  the  urethra  and  prostate  in 
the  male  and  from  the  vagina  in  the  female,  until  the  point  is  reached 
where  the  levatores  ani  are  attached  to  the  sides  of  the  rectum. 
This  represents  the  boundary  between  the  upper  and  lower  parts  of 
the  operation.     The  levatores  ani  are  cut  close  to  the  wall  of  the 


586  RECTUM. 

rectimi  and  the  rectum  then  removed.  The  perineal  incision  is  closed 
in  part  and  a  ping  of  gauze  left  in  for  drainage. 

The  entire  operation  can  be  done  by  a  single  operator  or  a 
second  operator  may  do  the  work  from  below.  The  abdominal  incision 
may  be  left  open  (or  partly  closed  with  a  few  temporary  sutures) 
until  the  perineal  part  of  the  operation  has  been  completed,  when 
the  first  operator  or  the  single  operator,  if  only  one,  may,  with  a 
change  of  gloves,  complete  the  operation  by  suturing  the  edges  of 
the  torn  peritoneal  lining  of  the  pelvic  floor  and  closing  the  abdominal 
incision. 

Combined  Operation  v^ith  Suture  of  the  End  of  the  Sig- 
moid TO  THE  Anal  Margin  or  to  the  Anal  Portion. — In  those 
cases  where  there  is  a  suflficient  length  of  sigmoid  flexure  (pelvic  colon) 
left  after  the  diseased  part  of  the  bowel  has  been  resected,  it  may 
be  decided  to  pull  down  the  end  of  the  sigmoid  and  suture  it  to  the 
anal  margin  if  it  has  been  possible  to  preserve  the  external  sphincter ; 
or  to  anastomose  it  to  the  anal  portion  of  the  rectum  if  this  part 
remains.  Special  care  will  be  necessary  to  preserve  enough  of  the 
blood-supply  of  the  sigmoid  to  insure  the  nutrition  of  the  end  of  the 
bowel  which  is  drawn  down  for  suture,  to  the  anal  margin  or  to  the 
anal  portion  of  the  rectum.  Care  must  be  exercised,  in  ligating  the 
superior  hemorrhoidal,  to  secure  the  vessel  below  the  level  of  the 
promontory  of  the  sacrum,  that  is,  below  the  point  where  the  sigmoid 
branches  are  given  off  from  the  inferior  mesenteric.  The  sigmoid 
flexure  (pelvic  colon)  depends  upon  these  vessels  for  its  vascular 
supply  (see  Fig.  261). 

With  Suture  of  the  End  of  the  Bowel  to  the  Anal 
Margin. — The  abdomen  is  opened  and  the  sigmoid  flexure  drawn 
up  into  the  incision  and  cut  across,  low  down,  as  close  to  the  growth 
as  may  be,  between  two  heavy  silk  ligatures  which  have  been  tied 
around  the  bowel. 

The  ends  of  the  ligatures  are  left  long  to  serve  as  tractors.  The 
two  ends  of  the  gut  are  carefully  cleansed.  The  end  of  the  upper 
segment  is  wrapped  in  gauze  and  placed  to  one  side  temporarily. 
The  mesosigmoid,  corresponding  to  the  lower  segment,  is  tied  off 
with  one  or  two  ligatures  as  far  as  the  point  where  the  mesentery 
ceases  to  exist,  where  the  pelvic  colon  becomes  continuous  with  the 
rectum.  The  ligatures  are  each  applied  double  so  that  the  mesentery 
can  be  divided  between  them.  The  superior  hemorrhoidal  artery  is 
secured  below  the  level  of  the  promontory  of  the  sacrum,  below  the 


OPERATIONS  UPOX  THE  ANUS  AND  RECTUM.  587 

point  where  the  sigmoid  branches  are  given  off  from  the  inferior 
mesenteric.  The  detachment  of  the  rectum  is  continued  as  far  down 
as  possible. 

A  second  operator  working  from  below,  through  the  perineal 
incision,  detaches  the  rectum  and  removes  it  (see  "Perineal  Method," 
page  569),  and  then  passes  a  forceps  up  through  the  perineal  incision 
into  tlie  pelvic  cavity  and  grasps  the  ends  of  the  silk  ligature  which 
closes  the  end  of  the  upper  segment  of  the  bowel  (the  end  of  the 
sigmoid),  and  draws  this  part  of  the  bowel  down  and  out  through 
the  anal  incision.  The  bowel  should  come  down  without  any  tension 
whatever.  There  may  be  some  difficulty  in  drawing  the  end  of  the 
bowel  down  to  the  anal  margin  on  account  of  the  shortness  of  the 


Fig.    262.— Resection  of   Rectum,    Abdomino-anal    Method.     The    diseased   portion 
has  been  tied  off  and  cut  away  from  the  healthy  bowel  above  and  below. 

mesentery  that  attaches  it  near  the  left  sacro-iliac  synchondrosis. 
This  difficulty  may  be  overcome  by  incising  the  mesosigmoid  near  its 
attachment  to  the  pelvic  brim  and  without  jeopardizing  its  blood- 
supply,  provided  the  sigmoid  arteries  which  are  given  off  from  the 
inferior  mesenteric  just  before  it  dips  into  the  pelvic  cavity  to 
become  the  superior  hemorrhoidal,  are  not  injured. 

The  end  of  the  sigmoid  which  has  been  drawn  down  and  out 
through  the  anal  incision  is  sutured  to  the  edges  of  the  skin  around 
the  anus.  If  the  external  sphincter  has  been  preserved  we  may 
expect  a  fairly  continent  anus. 

With  Anastomosis  of  the  End  of  the  Sigmoid  to  the  Lowee, 
Anal  Portion. — The  diseased  portion  of  the  bowel  may  be  resected 
by  the  operator  working  through  the  abdominal  incision,  leaving  the 
lower  part  of  the  rectum  so  that  the  end  of  the  sigmoid  flexure  may 
be  anastomosed  to  this  lower  portion  of  the  rectum. 


588 


RECTUM. 


Two  heavj'  silk  ligatures  are  tied  aroiTiid  the  lower  part  of  the  rec- 
tum after  it  has  been  detached,  and  the  diseased  joart  of  the  bowel  is 
removed  by  dividing  the  bowel  between  the  two  ligatures.  A  second 
operator  working  from  below  inserts  a  forceps  through  the  anus,  up  into 
the  blind  pocket  which  corresponds  to  the  lower,  anal  part  of  the  rectum 


Fig.  263. — Resection  of  the  Rectum,  Abdomino-anal  Method.  The  lower, 
anal  segment  of  the  rectum  is  everted  through  the  anal  orifice.  The  forceps 
is  passed  up  through  the  lower,  everted  end  of  the  bowel  and  grasps  the  end 
of  the  upper  segment. 

and  seizes  the  tied-off  end  and  draAvs  it  out  through  the  anus,  thus 
evertijHg  this  part  of  the  bowel — turning  it  inside  out.  This  step  of 
the  operation  may  be  facilitated  by  the  first  operator,  from  above, 
pushing  the  tied  end  of  the  lower  piece  of  the  rectum  into  the  grasp 


Fig.  264.— Resection  of  the  Rectum,  Abdomino-anal  Method.  The  upper 
segment  has  been  drawn  down  through  the  lower,  everted  segment.  The  edges 
of  the  two  segments  have  been  sutured  together  and  the  parts  are  ready  to  be 
returned  into  the  pelvis. 

of  the  forceps  or  the  tails  of  the  ligature  which  secures  the  end  of 
this  segTiient  of  the  bowel  may  be  threaded  in  the  eye  of  a  probe  and 
the  probe  pushed  through  the  middle  of  the  tied-off  stump  and  out 
through  the  anus.  The  tails  of  the  ligature  may  then  be  used  as 
tractors  to  evert  the  lower  segment  of  the  bowel.     The  ligature  is 


OPERATIONS  UPOX  THE  ANUS  AND  RECTUM.  589 

removed  from  the  end  of  the  everted  lower  end  of  the  bowel  and  the 
forceps  is  again  passed  up  into  the  pelvis  through  the  everted  anal 
portion.  The  tails  of  the  suture  which  secures  the  end  of  the  sigmoid 
portion  are  seized  and  this  end  of  the  bowel  is  pulled  down  and  out 
through  the  everted  anal  portion,  "telescope"  fashion.  The  edges 
of  the  two  segments  are  sewed  together,  all  around,  with  interrupted 
silk  sutures  placed  close  together.  The  edges  of  the  two  segments 
are  thus  united  very  accurately. 

After  the  end  of  the  sigmoid  has  been  sutured  to  the  anal  por- 
tion the  bowel  is  returned  through  the  anus  into  the  pelvic  cavity. 
A  plug  of  gauze  is  introduced  through  an  incision  which  is  made 
behind  the  anus,  reaching  well  up  into  the  pelvis,  into  the  connective- 
tissue  space  behind  the  rectum,  for  the  pui-pose  of  drainage.  A  rubber 
tube  wrapped  around  with  gauze  is  introduced  into  the  rectum,  up 
beyond  the  line  of  suture,  to  protect  the  suture  line  and  to  permit 
the  escape  of  gas. 

The  operator  from  above  restores  the  peritoneal  lining  of  the 
pelvic  floor  by  suturing  the  torn  edges  of  the  same  and  closes  the 
abdominal  incision. 


PART  VII. 

HERNIA,  SPERMATIC  CORD,  TESTES,  ETC. 

The  Surgical  Anatomy  of  the  Groin. — The  groin  may  be  divided 
into  the  inguinal  and  femoral  regions.  These  parts  may  be  consid- 
ered more  or  less  together,  on  aeconnt  of  the  close  relationship  that 
exists  between  them. 

The  inguinal  region  corresponds  to  that  part  of  the  anterior 
abdominal  wall  which  lies  just  above  Poupart's  ligament,  and  is 
traversed  by  a  canal  for  the  passage  of  the  spermatic  cord,  in  the 
male,  and  the  round  ligament,  in  the  female.  By  invaginating  the 
integument  of  the  scrotum,  the  finger  may  be  introduced  into  this 
canal. 

The  femoral  region  corresponds  to  the  upper  anterior  part  of 
the  thigh — the  area  immediately  below  Poupart^s  ligament.  Under- 
neath Poupart^s  ligament,  between  it  and  the  pubic  bone,  there  is  a 
space  through  which  the  ilio-psoas  muscle  and  anterior  crural  nerve, 
and  the  femoral  vessels,  etc.,  pass  from  the  abdomen  into  the  thigh. 

The  Superficial  Layer  of  the  Superficial  Fascia. — ^Be- 
neath  the  skin  of  the  groin  there  is  a  loose  connective-tissue  layer 
which  contains  a  varying  amount  of  fat,  and  in  which  the  blood- 
vessels, nerves,  lymphatic  glands,  etc.,  are  located.  This  layer  is 
called  the  superficial  layer  of  the  superficial  fascia.  In  some  subjects 
it  is  very  thick.  It  is  continuous  with  the  general  fatty  layer  of  the 
body.  In  the  male  it  is  continued  on  to  the  penis,  where  it  is  thin 
and  loose,  forming  one  of  the  coats  of  that  organ,  and  in  the  scrotum 
is  continued  into  the  dartos.  From  the  scrotum  it  may  be  traced 
back  into  the  perineum,  where  it  is  known  as  the  superficial  layer 
of  the  superficial  perineal  fascia.  In  the  female  it  is  continuous  with 
the  fatty  layer  of  the  labia  majora,  each  one  of  which  corresponds 
to  one-half  of  the  scrotum.  The  vessels  which  are  found  in  this 
layer,  and  which  may  be  cut  in  making  the  skin  incisions  in  operating 
upon  these  parts,  are  the  superficial  epigastric,  superficial  circumflex 
iliac,  and  superficial  external  pubic  arteries,  together  with  their  cor- 
responding veins. 
(590) 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  591 

The  Lymphatic  Gi^vnds. — The  lymphatic  glands  of  this  region 
are  arranged  in  two  groups :  one  group,  the  inguinal,  is  spread  along 
Poupart's  ligament,  and  drains  the  external  genitals,  scrotum,  penis, 
etc.;  the  other  gi'oup  lies  along  the  saphenous  vein,  and  in  and  ahout 
the  saphenous  opening.  These  drain  the  lower  limb.  In  extirpating 
the  inguinal  group  of  glands  tliere  is  but  little  hemorrhage,  but  it 
is  necessar}^  to  avoid  the  spermatic  cord.  In  extirpating  the  lower, 
femoral,  group  there  may  be  considerable  hemorrhage,  and  one  must 
avoid  injury  to  the  internal  saphenous  vein  and  to  the  femoral  vein, 
especially  when  excising  those  glands  that  are  lodged  in  the  saphe- 
nous opening. 

The  Deep  Layer  of  the  Superficial  Fascia. — After  the  fatty 
layer  has  been  removed  from  this  region  the  deep  layer  of  the  super- 
ficial fascia  is  exposed.  This  fascia  is  thin,  and  covers  the  aponeu- 
rosis of  the  external  oblique  muscle  in  the  inguinal  region,  and  the 
fascia  lata  in  the  femoral  region.  It  is  adherent,  in  the  middle  line, 
to  the  linea  alba,  and,  just  below  Poupart's  ligament,  to  the  fascia 
lata.  In  the  male  it  forms  one  of  the  coverings  of  the  penis,  and  is 
continued  into  the  scrotum,  where  it  forms  the  dartos,  and  backward 
beyond  the  scrotum,  into  the  perineum,  where  it  forms  the  deep  layer 
of  the  superficial  perineal  fascia.  In  the  perineum  it  is  attached 
laterally  to  the  rami  of  the  pubes,  and  behind  to  the  transverse  peri- 
neal raphe.  In  the  female  this  layer  is  continued  into  the  labia 
majora.  This  fascia  is  firmly  attached  to  the  margins,  or  pillars,  of 
the  external  ring,  and  is  known  as  the  external  spermatic  fascia. 
Entrance  into  the  inguinal  canal  cannot  be  effected  until  this  layer 
of  fascia  has  been  incised.  From  the  margins  of  the  ring  this  layer 
of  fascia  is  continued  downward,  surrounding  the  cord  and  forming 
one  of  its  investments,  and  below,  as  already  mentioned,  it  is  found 
in  the  scrotum  as  the  dartos.  Below  Poupart's  ligament,  in  the 
femoral  region,  this  layer  of  fascia  is  firmly  adherent  to  the  margins 
of  the  saphenous  opening  in  the  fascia  lata,  where  it  is  perforated 
by  numerous  vessels  and  lymphatics,  and  is  called  the  cribriform 
fascia.  From  this  point  on,  the  inguinal  and  femoral  regions  may  be 
studied  separately. 

The  Inguinal  Region. — The  inguinal  region  is  the  site  of  in- 
guinal hernia.  After  removing  the  deep  layer  of  the  superficial 
fascia  from  the  inguinal  region  (including  the  margins  of  the  exter- 
nal ring),  we  expose  the  aponeurosis  of  the  external  oblique  and  the 
external  inguinal  ring,  into  which  the  finger  may  be  introduced,  and 


592  HERNIA,  ETC. 

from  Avhicli  the  spermatic  cord   (the  round  ligament  in  the  female) 
is  seen  to  emerge. 

The  aponeurosis  of  the  external  oblique  is  the  strong,  smooth, 
glistening,  bluish-white,  fibrous  expansion  of  the  external  oblique 
muscle.  Its  fibers  have  an  oblique  direction  downward  and  inward 
toward  the  middle  line,  and  join  with  each  other  in  the  linea  alba. 
The  lower  fibers  of  the  aponeurosis  of  the  external  oblique  are  col- 
lected into  a  thick  bundle  to  form  Poupart's  ligament 

Poupart's  ligament  is  a  strong,  fibrous  band  which  extends  from 
the  anterior  superior  spinous  process  of  the  ilium  downward  and 
inward  to  the  spine  of  the  pubes.  Both  these  bony  processes  are 
easily  made  out;  the  latter,  the  spine  of  the  pubes,  is  readily  felt 
beneath  the  soft  parts  upon  the  upper  border  of  the  pubic  bone, 
about  three-fourths  inch  from  the  symphysis.  Tlie  fibers  of  the 
aponeurosis  of  the  external  oblique  immediately  above  Poupart's 
ligament  pass  inward  toward  the  middle  line,  interlacing  with  those 
from  the  opposite  side,  and  are  attached  to  the  symphysis,  and  there 
is  thus  left  a  triangular  opening  in  the  aponeurosis,  which  is  called 
the  external  inguinal  ring.  This  so-called  ring  is  simply  a  split  in 
the  aponeurosis  of  the  external  oblique.  Its  outer  or  lower  border, 
or  pillar,  is  formed  by  Poupart's  ligament;  its  inner  or  upper 
border,  or  pillar,  is  formed  by  those  fibers  of  the  aponeurosis  of  the 
■external  oblique  which  are  attached  in  the  middle  line  to  the  sym- 
physis, interlacing  with  those  of  the  opposite  side.  The  apex  of  this 
opening  is  directed  upward  and  outward;  its  base  corresponds  to  the 
crest,  or  upper  surface,  of  the  body  of  the  pubic  bone,  that  portion 
of  the  bone  which  is  included  between  the  pubic  spine,  to  which  Pou- 
part's ligament  is  attached,  and  the  symphysis.  Various  stay  fibers 
are  seen  in  the  aponeurosis,  passing  from  below  upward  and  inward, 
near  the  apex  of  the  external  ring.  These  serve  to  bind  the  pillars 
of  the  ring  firmly  together,  and  are  called  the  intercolumnar  fibers. 

The  spermatic  cord  (round  ligament  in  the  female)  is  seen 
emerging  from  the  external  ring,  and  a  director  may  be  introduced 
through  the  ring  upward  and  outward  into  the  inguinal  canal.  From 
the  inner  end  of  Poupart's  ligament — i.e.,  from  the  external  pillar 
of  the  ring — a  triangular  sheet  of  fibers  is  given  off,  which  is  reflected 
upward  and  inward  toward  the  middle  line,  and  is  continued  into  the 
anterior  layer  of  the  sheath  of  the  rectus  muscle.  This  is  called  the 
triangular  ligament,  or  CoUes's  ligament,  and  is  situated  behind  the 
inner  end  of  the  external  ring,  and  in  front  of  the  conjoined  tendon, 


Fig.  265.— Inguinal  and  Femoral  Regions.  FP,  edge  of  falciform  process;  FV, 
femoral  vein;  LA,  linea  alba;  LS,  linea  semilunaris;  P,  Poupart's  ligament. 
The  external  inguinal  ring  is  shown  with  the  spermatic  cord  emerging.  The 
fibers  crossing  the  upper  outer  angle  of  the  ring  are  known  as  the  intercolumnar 
fibers. 

38 


594  HERNIA,  ETC. 

and  serves  to  strengthen  this  part.  If  'Ave  examine  still  further  this 
inner  end  of  PoujDart's  ligament, — i.e.,  the  external  pillar  of  the 
ring, — we  find  given  off  from  its  lower  border,  just  before  its  attach-  . 
ment  to  the  pubic  spine,  a  strong  triangular  band,  which  is  attached 
to  the  ilio-pectineal  line,  a  prominent  ridge  upon  the  upper  surface 
of  the  pubic  bone,  which  is  continued  outward  and  backward  from 
the  pubic  spine  to  the  edge,  or  brim,  of  the  true  pelvis.  This  band 
is  known  as  Gimbernat's  ligament.  It  presents  an  outer,  sharp, 
curved  edge,  and  is  of  much  anatomical  interest  in  the  study  of 
femoral  hernia. 

The  Inguinal  Canal. — The  inguinal  canal  is  an  oblique  slit  in 
the  abdominal  wall,  and,  under  ordinary  circumstances,  the  greater 
the  intra-abdominal  pressure,  the  tighter  its  closure.  It  is  from  4 
to  5  cm.  (one^and  one-half  inches)  long,  and  lies  above  and  parallel 
with  Poupart's  ligament.  It  terminates  beneath  the  integument  at 
the  external  inguinal  ring,  a  triangular  opening  in  the  aponeurosis  of 
the  external  oblique,  which  is  located  just  above  the  crest  of  the 
pubes. 

If  we  introduce  a  director  through  the  external  ring  into  the 
inguinal  canal,  and  pass  it  in  a  direction  upward  and  outward  under- 
neath the  aponeurosis  of  the  external  oblique,  to  a  point  about  half 
an  inch  above  the  middle  of  Poupart's  ligament, — i.e.,  the  location  of 
the  internal  ring, — and  then  split  the  aponeurosis  upon  this,  we 
open  up  the  inguinal  canal  and  expose  its  contents :  the  spermatic 
cord,  in  the  male ;  the  round  ligament,  in  the  female.  The  cut  edges 
of  the  aponeurosis  should  i)e  seized  with  artery  forceps  and  separated 
freely  from  the  underlying  parts  with  the  finger.  The  spermatic 
cord  is  a  structure  as  big  around  as  the  little  finer.  It  is  made  up 
of  the  vas  deferens,  which  is  the  efferent  duct  of  the  testicle;  the 
artery  of  the  vas  deferens  and  the  cremasteric  artery,  and  their 
corresponding  veins;  the  spermatic  artery,  and  the  pampiniform 
venous  plexus.  As  these  structures  traverse  the  inguinal  canal  they 
are  all  bound  together  into  a  single  rounded  cord  by  a  strong  sheath 
of  fascia,  the  infundibular  process  of  the  transversalis  fascia.  De- 
scending upon  the  cord  are  also  seen  the  fibers  of  the  cremaster 
muscle,  which  are  derived  from  the  lower  edge  of  the  internal  oblique 
in  the  descent  of  the  testes.  The  cord  is  also  accompanid,  in  its 
course  through  the  inguinal  canal,  by  the  genital  branch  of  the 
genito-crural  nerve  and  the  inguinal  branch  of  the  ilio-inguinal 
nerve. 


SURGICAL  ANATOMY  OF  THK  CROIX.   KTC. 


f)95 


Fig.  266. — The  Inguinal  Canal.  The  canal  has  been  laid  open  by  splitting 
the  aponeurosis  of  the  external  oblique  (A),  which  is  grasped  with  the  artery 
forceps  and  drawn  upward;  CT,  edge  of  the  internal  oblique  muscle  (conjoined 
tendon) ;  E,  dotted  line  represents  the  course  of  the  deep  epigastric  artery, 
which  is  located  beneath  the  transversalis  fascia;  P,  Poupart's  ligament;  TF, 
transversalis  fascia,  which  forms  the  posterior  wall  of  the  inguinal  canal;  TL, 
triangular  ligament,  which  is  given  off  from  the  inner  end  of  Poupart's. 


596  HERNIA,  ETC. 

After  the  inguinal  canal  has  been  opened  by  splitting  the  apo- 
neurosis of  the  external  oblique,  the  free,  curved,  fleshy  edge  of  the 
intemal  oblique  is  exposed  to  view.  This  muscle,  the  part  seen  here, 
arises  from  the  outer  half  of  Poupart's  ligement.  If  the  edge  of  this 
muscle  is  raised  and  drawn  upward  and  outward  for  a  short  distance, 
or  incised,  we  expose  the  transversalis  muscle,  which  lies  beneath  tne 
internal  oblique.  That  portion  of  the  transversalis  which  is  thus 
exposed  arises  from  the  outer  third  of  Poupart's  ligament,  and  is 
covered  by  the  internal  oblique,  and  is  not  seen  until  the  edge  of 
this  latter  muscle  has  been  drawn  aside. 

Toward  the  outer  part  of  the  inguinal  canal  these  two  muscles, 
where  they  arise  from  Poupart's  ligament,  are  situated  for  a  short 
distance  in  front  of  the  spermatic  cord.  They  then  arch  inward 
above  the  cord,  and,  joining  with  each  other,  become  tendinous,  and. 
as  the  conjoined  tendon,  descend  behind  the  cord,  to  be  attached  to 
the  upper  surface  of  the  pubic  bone;  i.e.,  the  crest  and  the  pectin- 
eal line.  The  conjoined  tendon,  at  its  attachment  to  the  pubic 
bone,  is  placed  behind  the  external  ring,  and  participates  in  the 
formation  of  the  inner  part  of  the  posterior  wall  of  the  inguinal 
canal.  It  is  important  to  note  that  that  portion  of  the  posterior 
wall  of  the  inguinal  canal  Avhich  is  included  between  the  arching 
free  edge  of  the  internal  oblique  muscle  above  and  Poupart's  liga- 
ment below  is  formed  by  the  transversalis  fascia  only.  This  fascia 
is  a  fibrous  layer  which  lines  the  whole  inner  surface  of  the  abdonien, 
including  the  posterior  surface  of  the  anterior  abdominal  wall,  and 
it  is  here  exposed  to  view  where  the  muscle  is  deficient ;  i.e.,  between 
the  edge  of  the  internal  oblique  muscle  above  and  Poupart's  ligament 
below.  Through  the  outer  part  of  the  posterior  wall  of  the  inguinal 
canal  the  several  structures  which  go  to  make  up  the  spermatic  cord 
(round  ligament  in  the  female)  pass  forward  into  the  inguinal 
canal,  being  provided  with  a  strong,  fibrous  sheath,  which  is  known 
as  the  infundibular  process,  by  the  fascia  transversalis.  This  sheath 
incloses  the  several  elements  of  which  the  cord  is  composed,  and 
serves  to  bind  them  together  into  a  single  bundle,  which  traverses 
the  inguinal  canal  and  emerges  at  the  external  inguinal  ring.  The 
point  at  which  the  structures  which  constitute  the  spermatic  cord 
pass  forward  into  the  inguinal  canal  is  the  site  of  the  internal  ingui- 
nal ring.  The  internal  ring  is  an  opening  in  the  transversalis  fascia, 
which  is  located  half  an  inch  above  the  middle  of  Poupart's  liga- 
ment.    The  inguinal  canal  proper  has  no  internal  opening;  i.e.,  it 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  597 

does  not  communicate  with  the  abdominal  cavity.  The  internal  in- 
guinal ring  is  really  the  mouth  of  the  infundibular  process,  \yhich 
is,  in  reality,  the  sheath  that  is  provided  to  the  spermatic  cord  from 
the  transversalis  fascia. 

The  infundibular  process  is  a  glove-finger-like  diverticulum,  or 
pocket,  which  is  derived  from  the  fascia  transversalis,  being  pro- 
longed downward  into  the  bottom  of  the  scrotal  sac,  and,  through 
this,  the  testicle,  drawing  the  vas  deferens,  etc.,  after  it,  descends 
in  its  journey  from  the  abdomen  into  the  scrotum.  After  the  testis 
has  reached  the  bottom  of  the  scrotal  sac,  the  upper  part  of  this 
infundibular  process — i.e.,  the  part  which  corresponds  to  the  cord 
— contracts  and  shrinks  so  closely  around  the  structures  which  make 
up  the  cord,  and  which  are  contained  within  it,  that  its  cavity  is, 
in  this  way,  entirely  obliterated,  and  the  shrunken  infundibular 
process  remains  permanently  as  the  proper  fibrous  sheath  of  the 
spermatic  cord. 

The  lower  part,  however,  of  the  infundibular  process  remain? 
permanently  unchanged  as  one  of  the  layers  of  the  scrotum. 

The  contraction  of  the  infundibular  process  about  the  upper 
part  of  the  cord  may  be  incomplete,  and  there  may  be  thus  left  a 
space  within  the  sheath  of  the  cord  (infundibular  process),  into 
which  the  point  of  the  finger  may  be  insinuated  from  within  the 
abdomgn.  The  finger  under  these  circumstances  does  not  enter  the 
inguinal  canal,  but  passes  through  the  internal  ring  into  the  proper 
sheath  of  the  spermatic  cord.  The  mouth  of  the  infundibular 
process,  the  "internal  ring,"  may  be  best  studied  from  within  the 
abdomen,  after  the  peritoneum,  which  lines  this  portion  of  tlio 
abdominal  wall,  has  been  stripped  aAvay. 

Beneath  the  transversalis  fascia — i.e.,  the  posterior  wall  of  the 
inguinal  canal — is  found  the  parietal  layer  of  the  peritoneum,  with 
an  intervening  stratum  of  loose  connective  tissue,  containing  fat,  be- 
tween it  and  the  transversalis  fascia;  this  is  the  so-called  subperi- 
toneal connective-tissue  layer.  The  layer  of  peritoneum  which  lies 
behind,  or  rather  beneath,  the  posterior  wall  of  the  inguinal  canal 
presents  no  opening  whatever.  Within  the  abdomen,  about  the 
mouth  of  the  infundibular  process,  "internal  ring,"  the  parietal  peri- 
toneum is  adherent  to  the  transversalis  fascia,  and  may  show  a  sliglit 
bulging  into  the  neck  of  the  infundibular  process  (sheath  of  the 
cord). 

In   the   study   of   these   parts  the   deep    epigastric   artery   plays 


598  HERNIA,  ETC. 

an  imi^ortant  role.  This  artery  may  be  seen,  or  its  pulsation  felt, 
as  it  lies  beneath  the  transversalis  fascia  in  the  subperitoneal  con- 
nective tissue  between  the  transversalis  fascia  and  the  peritoneum. 
The  artery  is  accompanied  by  one  or  two  veins.  It  arises  from  the 
external  iliac  (femoral)  just  before  this  vessel  passes  out  of  the  ab- 
domen under  Poupart's  ligament,  and  ascends  obliquely  upward  and 
inward  toward  the  umbilicus  to  reach  the  outer  border  of  the  rectus 
muscle.  It  passes  across  the  posterior  wall  of  the  inguinal  canal 
about  the  middle,  and  so  divides  it  into  two  parts,  an  outer  and  an 
inner.  The  outer  part  of  the  posterior  Avail  of  the  inguinal  canal, 
that  part  which  lies  external  to  the  deep  epigastric  artery,  is  formed 
by  the  transversalis  fascia  and  the  underlying  peritoneum,  and  pre- 
sents the  opening  through  which  the  structures  that  form  the 
spermatic  cord  (round  ligament)  leave  the  abdomen,  the  internal 
ring.  The  presence  of  this  orifice  tends  to  weaken  this  outer  part 
of  the  posterior  wall  of  the  inguinal  canal.  The  inner  portion  of  the 
posterior  wall  of  the  inguinal  canal,  that  part  which  lies  internal 
to  the  deep  epigastric  artery,  is  strengthened,  in  part,  by  several 
additional  layers.  From  before  backward  this  part  of  the  posterior 
wall  of  the  inguinal  canal  is  formed  of  the  triangular  ligament, 
conjoined  tendon,  transversalis  fascia,  and  parietal  peritoneum. 
This  inner  portion  of  the  posterior  wall  of  the  inguinal  canal  is, 
therefore,  much  more  secure  than  the  outer  ]3art. 

A  hernia  that  protrudes  through  the  posterior  wall  of  the  in- 
guinal canal  external  to  the  deep  epigastric — i.e.,  one  which  passes 
through  the  "internal  ring"  and  works  its  way  downward  along  the 
cord — is  an  oblique,  or  external,  inguinal  hernia,  the  common  va- 
riety. In  those  cases  in  which  the  upper  part,  or  neck,  of  the  infun- 
dibular process  has  failed  to  become  tightly  contracted  around  the 
elements  of  the  cord  right  up  to  the  point  at  which  they  emerge 
from  the  abdomen,  the  predisposition  to  hernia  is,  without  doubt, 
more  pronounced,  and  this  is  especially  the  case  if,  in  addition,  the 
peritoneum,  which  is  normally  adherent  about  the  site  of  the  "in- 
ternal ring,"  shows  a  certain  degree  of  bulging  into  the  mouth  of 
the  patent  infundibular  process. 

A  hernia  that  bulges  forward  through  the  posterior  wall  of  the 
inguinal  canal  to  the  inner  side  of  the  deep  epigastric  artery  is  a 
direct,  or  internal,  inguinal  hernia.  Such  a  hernia  does  not  pass 
through  the  "internal  ring"  and  descend  along  the  course  of  the 
cord,  within  its  sheath    (infundibular  process),  but  bulges  directly 


SURGICAL  AXATU-MV  UF  THE  GROIN,  ETC.  599 

forward  into  the  inuruinal  canal,  to  the  inner  side  of  the  cord,  and, 
besides  the  transversal  is  fascia,  it  may  have  to  push  the  conjoined 
tendon,  etc.,  before  it,  or  else  force  its  Avay  between  the  fibers  of 
this  structure.  These  accessory  structures  form  a  strong  barrier 
against  the  formation  of  a  direct  hernia,  which  variety  is  much 
less  common  than  the  oblique. 

In  the  female  the  inguinal  canal  and  rings  are  all  less  well  de- 
veloped than  in  the  male.  The  round  ligament  is  a  thin  structure, 
often  difficult  to  find.  After  passing  through  the  inguinal  canal 
it  emerges  from  the  external  ring,  and  is  then  lost  in  the  connect- 
ive tissue  about  the  external  ring  and  in  the  labia  majora. 

Inguinal  hernia  is  comparatively  infrequint  in  the  female. 
When  it  occurs,  it  is  analogous  to  that  in  the  male,  and  may  de- 
scend into  the  labia  majora. 

The  Descext  of  the  Testes. — The  testes  (ovaries  in  the 
female)  are  developed  within  the  abdomen  from  the  Wolffian  body, 
and  in  early  foetal  life  they  are  situated  in  the  back  part  of  the 
abdominal  cavity  near  the  kidneys.  They  lie  not  within  the  peri- 
toneal cavity,  but,  like  the  kidney,  behind  the  peritoneum,  which 
is  adherent  to  their  front  surface.  From  this  position,  the  testes, 
during  the  later  months  of  foetal  life,  gradually  descend.  They  de- 
scend behind  the  peritoneum  and  enter  the  infundibular  process 
through  its  mouth,  the  "internal  ring."  Finally,  during  the  last 
month  of  intra-uterine  life  they  arrive  at  their  normal  destination, 
the  bottom  of  the  scrotal  pouch. 

The  ovaries  descend  in  an  analogous  manner,  but  do  not  pass 
out  of  the  abdominal  cavity. 

Preparatory  to  the  descent  of  the  testes  there  is  a  pouch-like 
bulging  of  the  lower  part  of  the  anterior  abdominal  wall  in  either 
inguinal  region.  A  shallow  pouch  is  thus  formed  on  either  side, 
which  gradually  becomes  deeper,  and  finally  the  two  join  together 
in  the  middle  line  to  form  the  scrotum.  Each  of  these  pouches  is 
lined  on  its  internal  aspect  by  a  sac-like  prolongation  from  the  trans- 
versalis  fascia  (infundibular  process).  These  pouches  are  empty 
and  ready  to  receive  the  testes. 

Beaching  from  the  testis  as  it  lies  within  the  abdomen,  down- 
ward into  the  bottom  of  the  infundibular  process  (scrotum),  there 
is  a  musculo-fibrous  structure,  the  gubernaculum  of  Hunter.  It 
serves  to  lead  the  testis  down  into  the  scrotal  sac. 

About  the  sixth  month  of  foetal  life  the  descent  of  the  testis 


600  HERNIA,  ETC. 

begins.  The  gubernaculum  contracts  and  draws  tlie  testis  downward 
toward  the  inguinal  region.  About  the  seventh  month  the  testis 
arrives  at  the  "internal  ring,"  the  wide-open  mouth  of  the  infun- 
dibular process.  The  testis  then  passes  into  the  infundibular  proc- 
ess, and,  as  it  does  so,  it  brings  a  bag-like  process  of  the  peritoneum, 
which  is  adherent  to  it,  with  it.  This  is  called  the  vaginal  process 
i>f  the  peritoneum.  At  the  eighth  month  the  testis  is  found  in  the 
infundibular  pouch,  together  with  the  vaginal  process  of  the  peri- 
toneum, Avhich  accompanies  it,  and  during  the  last  month  of  intra- 
uterine life  it  is  found  at  the  bottom  of  the  infundibular  pouch,  the 
scrotum,  together  with  its  vaginal  peritoneal  process. 

The  testis  may  be  interrupted  in  its  journe}^  into  the  scrotum 
at  any  point,  and  may  remain  stationary  either  in  the  abdomen  or 
in  the  inguinal  canal.  This  condition  occasionally  complicates  con- 
genital hernia.  After  the  testis  has  reached  the  bottom  of  the 
scrotal  sac,  the  peritoneal  pouch,  which  accompanied  it,  becomes, 
for  that  part  of  its  extent  which  corresponds  to  the  vas  deferens, 
gradually  obliterated.  This  process  of  obliteration  commences  in 
the  middle  of  the  tube  and  extends  upward  toward  its  abdominal 
orifice,  and  downward  toward  the  testis,  and,  in  the  adult,  this  ob- 
literated portion  of  the  vaginal  process  is  represented  only  by  a 
fibrous  strand  that  is  found,  together  with  the  vas  deferens,  etc., 
inclosed  within  the  proper  sheath  of  the  cord. 

The  lower  part  of  the  vaginal  process,  that  portion  which  corre- 
sponds to  the  testis,  remains  permanently  as  the  tunica  vaginalis 
testis.  At  birth  the  canal  of  the  vaginal  process  is  still  pervious, 
but  very  much  shrunken,  and  becomes  rapidly  obliterated  during 
the  first  few  weeks  of  extra-uterine  life. 

If  the  peritoneal  pouch,  the  vaginal  process,  which  accompanies 
the  testis  in  its  descent,  remains  pervious  after  birth  throughout 
its  whole  extent,  and,  if  its  orifice  is  large  enough  to  permit,  a  coil 
of  intestine  may  enter;  and  we  shall  then  have  a  congenital  hernia. 

In  the  female  the  round  ligament  is  the  remains  of  the  guber- 
naculum.  The  ovary  descends  like  the  testis,  but  does  not  leave  the 
abdominal  cavity;  it  remains  in  the  pelvis.  It  does,  however,  ex- 
ceptionally leave  the  abdominal  cavity,  and  may  then  be  found  in 
the  labia  majora.     Congenital  hernia  is  uncommon  in  the  female. 

To  recapitulate:  There  are  two  varieties  of  inguinal  hernia, 
the  direct,  or  internal,  and  the  oblique,  or  external.  The  direct 
is  always  acquired,  and  is  less  common  than  the  indirect.     In  this 


1.  At  Sixth  Month. 

Testis   located  in   the   back  part   of   the   abdominal    cavity,    covered   by  the 

peritoneum  upon  its  anterior  aspect. 
G,   gubernaculum  of  Hunter. 

IP,  infundibular  process  of  the  transversalis  fascia- 
P,  peritoneum  lining  the  interior  of  abdominal  cavity. 
S,  scrotum. 
T,  testis. 

TF,  transversalis  fascia. 
Tl),  vas  deferens. 

2.  At  the  Seventh  Month. 

The  testis  has  descended  into  the  inguinal  region  toward  the  mouth  of 
the   infundibular  process — future  internal   inguinal  ring. 

3.  At  the  Eighth  Month. 

The  testis  has  entered  the  infundibular  process,   carrying  a  process  of  the 

peritoneum  with  it. 
TP,   vaginal  process  of  peritoneum. 

4.  At  Ninth  Month. 

Testis  has  reached  the  bottom  of  the  infundibular  process, — scrotum, — 
carrying  process  of  peritoneum  with  it. 

5.  Third  to  Fourth  Week  after  Birth. 

Testis  is  located  in  the  bottom  of  the  infund,ibular  process — scrotum. 
Obliteration  has  begun  in  the  vaginal  process. 

6.  Several  Months  after  Birth. 

Normal  adult  condition. 

Testis  rests  in  bottom  of  infundibular  process — scrotum.  The  vaginal 
process  which  accompanied  the  testis  in  its  descent  has  become 
obliterated  except  for  that  portion  of  its  extent  which  corresponds  to 
the  testis.     This  remains  as  the  tunica  vaginalis  testis. 

CT,  cavity  of  tunica  vaginalis  testis. 


Fig.  267.— Descent  of  the  Testis. 


602  HERNIA,  ETC. 

variety  a  pouch  of  peritoneum  (the  hernial  sac) — containing,  for  ex- 
ample, a  loop  of  gnt — simply  forces  that  part  of  the  posterior  wall 
of  the  inguinal  canal  that  lies  to  the  inner  side  of  the  deep  epigastric 
artery  before  it  into  the  inguinal  canal,  and  finally  down  through 
the  external  ring. 

The  oblique  variety  may  be  either  congenital  or  acquired. 

A  congenital  hernia  is  due  to  the  absence  of  obliteration  in  the 
vaginal  peritoneal  process.  If  this  process  remains  patent  through- 
out its  entire  length,  the  hernial  contents — for  example,  a  coil  of  gut 
— simply  drop  into  the  open  pouch,  and  we  have  the  usual  form  of 
congenital  hernia. 

An  acquired  oblique  hernia  is  produced  after  the  vaginal  process 
has  become  completely  and  permanently  obliterated.  In  this  variety 
the  contents— for  example,  a  coil  of  gut — must  force  an  entirely  new 
pouch  of  peritoneum,  which  constitutes  the  hernial  sac,  before  it. 
This  peritoneal  sac  enters  the  mouth  of  the  infundibular  process 
("internal  ring"')  like  a  wedge,  and  works  its  way  downward  along  the 
spermatic  cord,  inclosed  within  the  sheath  of  the  cord  (infundibular 
process),  which  it  simply  distends;  or  else,  after  passing  through  the 
internal  ring  into  the  infundibular  process  (sheath  of  the  cord),  it 
causes  a  bulging  of  a  circumscribed  portion  of  the  sheath  of  the  cord, 
with  the  result  that  a  pocket,  or  pouch,  is  formed,  which  is  usually 
an  offshoot  from  the  proper  sheath  of  the  cord,  and  in  this  pouch  the 
hernial  peritoneal  sac  is  found,  together  with  the  hernial  contents. 

An  acquired  hernia  may  traverse  the  whole  length  of  the  in- 
guinal canal  and  enter  the  scrotum,  but  its  sac  is  always  entirely 
distinct  from  the  original  vaginal  peritoneal  process,  and,  its  con- 
tents are  never  to  be  found  in  the  same  cavity  with  the  testis,  as 
is  the  case  in  the  congenital  variety. 

A  partial  obliteration  of  the  vaginal  process  of  the  peritoneum 
may  occur,  and  we'may  then  have  an  infantile,  or  encysted,  hernia. 
In  this  case  the  vaginal  process  is  occluded  at  or  near  its  mouth, 
but  remains  open  throughout  a  part  of  its  extent  below.  We  then 
have  a  hernia,  with  its  own  newly  acquired  peritoneal  sac,  like  an 
ordinary  acquired  hernia,  passing  through  the  internal  ring  and 
downward  within  the  sheath  of  the  cord,  pushing  the  closed,  but 
unobliterated,  vaginal  peritoneal  process  in  front  of  it.  When  such  a 
hernia  is  operated  upon,  it  looks  as  though  there  were  two  separate 
and  distinct  sacs.  The  unobliterated  vaginal  process,  within  which 
the  testis  is  found,  is  entered  first,  and  then  a  second  serous  sac,  the 


Fig.  268. — Normal  Condition  of  Inguinal  Region,  Scrotum,  etc.  Testis  in 
bottom  of  scrotum  and  vaginal  process  obliterated.  CT,  cavity  of  tunica 
vaginalis  testis;  IN,  intestine  within  abdominal  cavity;  IR,  internal  inguinal 
ring — the  mouth  of  the  original  infundibular  process  of  the  transversalis  fascia; 
P,  peritoneum  lining  abdominal  cavity;  TF,  transversalis  fascia;  VD,  vas 
deferens;   TP,  vaginal  process  of  peritoneum — obliterated. 


Fig.  269.— Condition  of  Parts  in 
Presence  of  a  Congenital  (Oblique  In- 
guinal) Hernia.  Note  that  the  vaginal 
process  is  patent,  unobliterated,  and 
that   a  coil   of  intestine   has  entered. 


Fig.  270.— Condition  of  Parts  in 
Presence  of  an  Acquired  Oblique  In- 
guinal Hernia.  Note  that  the  vaginal 
process  (FP)  is  obliterated  and  that  a 
coil  of  intestine  has  pushed  its  way 
down  into  the  original  infundibular 
process  (sheath  of  the  spermatic  cord), 
driving  a  new  process  of  peritoneum 
(S)  before  it.  This  peritoneal  process 
forms  the  sac  of  the  hernia. 


604  HERNIA,  ETC. 

true  hernial  sac,  is  met  with  and  incised,  and  within  this  the  hernial 
contents  are  encountered. 

The  Femoral  EEGioisr. — The  area  immediately  below  Poupart's 
ligament  is  known  as  the  femoral  region. 

The  Fascia  Lata  is  exposed  after  the  skin  and  superficial  fascia 
have  been  removed.  This  is  a  strong,  apenourotic  layer  which  en- 
tirely surrounds  the  muscles  of  the  thigh,  and  serves  to  bind  them 
into  a  compact  mass.  It  is  attached  above,  in  front,  to  the  whole 
length  of  Poupart's  ligament,  from  the  pubic  spine  to  the  anterior 
superior  iliac  spine;  externally,  to  the  crest  of  the  ilium;  behind, 
to  the  sacrum ;  and,  internally,  to  the  rami  of  the  pubes  and  ischium. 

Just  below  Poupart's  ligament,  where  the  internal  saphenous 
vein  enters  the  femoral  vein,  the  fascia  lata  presents  an  oval  open- 
ing, the  saphenous  opening.  It  is  only  exposed  after  the  cribriform 
fascia  (that  part  of  the  deep  layer  of  the  superficial  fascia  which  is 
attached  to  the  margins  of  the  saphenous  opening)  has  been  re- 
moved. The  outer  margin  of  the  saphenous  opening  is  sharp  and 
curved,  and  was  called  by  Allan  Burns  the  falciform  |)rocess.  If 
the  falciform  process  is  traced  upward  and  inward,  it  is  found  to  be 
continuous  with  the  inner  end  of  Poupart's  ligament  and  with  Gim- 
bernat's  ligament,  some  of  its  fibers  being  attached,  with  this  latter 
ligament,  to  the  pubic  bone.  Below,  the  falciform  process  is  seen 
to  curve  inward  underneath  the  internal  saphenous  vein,  becoming 
continuous  here  with  that  part  of  the  fascia  lata  which  covers  the 
pectineus  muscle  (pubic  portion  of  the  fascia  lata).  The  free  edge  of 
the  falciform  process,  and  that  part  of  the  fascia  lata  external  to 
it,  cover  the  femoral  sheath  upon  its  anterior  aspect,  and  are  known 
as  the  "iliac  portion"  of  the  fascia  lata.  It  is  attached  above  to  the 
whole  length  of  Poupart's  ligament,  and  externally  is  continuous 
with  the  sheath  of  the  sartorius  muscle. 

That  j)ortion  of  the  fascia  lata  upon  which  the  internal  saphe- 
nous vein  rests,  and  which  covers  the  pectineus  muscle,  may  be  traced 
upward,  under  Poupart's  ligament,  as  far  as  the  ilio-pectineal  line,  to 
which  it  is  attached,  and  from  which  the  pectineus  muscle  arises. 
This  is  known  as  the  "pubic  portion"  of  the  fascia:  lata.  Beneath  the 
femoral  vessels  this  pubic  portion  of  the  fascia  lata  is  continuous, 
extern all}^,  with  the  fascia  which  covers  the  ilio-psoas  muscle  (fascia 
iliaca).  Above,  under  Poupart's  ligament,  this  fascia,  which  covers 
the  pectineus  muscle,  is  thickened,  and  is  loiown  as  the  pubic  liga- 
ment of  Cooper.  ■  These  two  portions  of  the  fascia  lata,  the  iliac  and 


Sl'RGICAL  ANATOMY  OF  THE  GROIN,  ETC.  605 

pubic  portions,  are  so  arranged  that  a  slit-like  opening,  the  saphenous 
opening,  exists  between  them,  and  through  this  the  internal  saphe- 
nous vein  joins  the  femoral  vein. 

The  femoral  vessels,  inclosed  within  their  sheath,  are  sand- 
wiched in  between  these  two  portions  of  the  fascia  lata,  resting 
behind  upon  the  fascia  which  covers  the  pectineus  and  ilio-psoas 
muscles,  and  covered  in  front  by  the  iliac  portion  of  the  fascia  lata. 
The  two  portions  of  the  fascia  lata,  which  have  just  been  described, 
the  iliac  and  pubic  portions,  are  simply  parts  of  one  and  the  same 
fascia,  and  are  seen  to  be  directly  continuous  with  each  other,  below 
the  saphenous  opening  upon  the  front  of  the  thigh.  The  pubic 
portion  of  the  fascia  lata,  which  corresponds  to  the  pectineus  muscle, 
is,  as  already  said,  continuous  externally,  behind  the  sheath  of  the 
femoral  vessels,  with  the  iliac  fascia,  which  invests  the  ilio-psoas 
muscle.  One  should  not  confuse  the  names  "iliac  portion  of  the 
fascia  lata"  with  "iliac  fascia." 

Tlie  Space  Beneath  Poupart's  Ligament. — ^Through  this  space 
the  ilio-psoas  muscle  and  the  anterior  crural  nerve  and  the  femoral 
vessels  pass  out  of  the  abdomen  into  the  thigh. 

The  ilio-psoas  muscle,  with  the  anterior  crural  nerve,  occupies 
the  outer  part  of  the  space.  The  ilio-psoas  muscle  is  a  thick  mass 
of  muscle  which  has  its  origin  within  the  abdomen  from  the  iliac 
fossa,  bodies  of  the  lumbar  vertebra,  etc.  It  consists  of  the  psoas 
and  iliacus  muscles,  and  passes  downward  under  Poupart's  ligament 
into  the  thigh,  where  it  is  attached  to  the  lesser  trochanter  of  the 
femur  and  to  the  surface  of  the  bone  immediately  below  this. 

Within  the  abdomen  the  ilio-psoas  muscle  is  covered  l)y  a  thick 
fascia,  the  fascia  iliaca.  which  is  attached  to  the  bodies  of  the  lumbar 
vertebrae  and  to  the  sacrum,  to  the  crest  of  the  ilium,  and  to  the 
brim  of  the  pelvis. 

At  Poupart's  ligament,  that  part  of  the  iliac  faseii  which  covers 
the  outer  portion  of  the  ilio-psoas  muscle — i.e..  corresponding  to  the 
outer  third  of  Poupart's  ligament — does  not  pass  down  into  the 
thigh  with  the  muscle.  l)ut  is  attached  to  Poupart's  ligament,  whence 
it  is  retlected  upward,  becoming  continuous  with  the  transversalis 
fascia,  which  lines  the  whole  posterior  surface  of  the  anterior  ali- 
dominal  wall.  Internal  to  this,  linwever,  corresponding  to  the  inner 
portion  of  the  ilio-psoas  muscle,  the  fascia  which  covers  the  muscle 
passes  with  the  muscle,  underneath  Poupart's  ligament,  doAvn  into  the 
thigh,  and  in  tl^.e  ujiper  ])art  of  the  thigh  is  continuous,  behind  the 


606  HERNIA,  ETC. 

sheath  of  the  femoral  vessels,  with  the  fascia  which  covers  the  pectin- 
eus  muscle  (pubic  portion  of  the  fascia  lata).  Immediately  beneath 
Poupart's  ligament  the  iliac  fascia  is  thickened,  and  this  thickened 
portion  is  called  the  ilio-pectineal  ligament.  This  is  not  an  isolated 
ligamentous  band  of  fibers,  but  simply  a  thickened  portion  of  the 
fascia  iliaca  as  it  passes  with  the  ilio-psoas  muscle  under  Poupart's 
ligament  into  the  thigh.  It  extends  from  the  junction  of  the  outer 
and  middle  thirds  of  Poupart's  ligament  downward  and  inward  to 
the  ilio-pectineal  eminence,  and  serves  thus  to  divide  the  space  un- 
derneath Poupart's  ligament  into  two  portions:  an  outer,  the  ilio- 
psoas space,  which  contains  the  ilio-psoas  muscle  and  the  anterior 
crural  nerve,  and  an  inner  and  upper,  the  femoral  space,  through 
which  the  femoral  vessels  pass  from  the  abdomen  into  the  thigh. 

The  femoral  space  is  bounded  above  by  Poupart's  ligament; 
below,  it  is  bounded  externally  by  the  ilio-pectineal  ligament,  and, 
internally,  by  the  pubic  ligament  of  Cooper.  The  so-called  pubic 
ligament  of  Cooper  is  simply  the  thickened  upper  portion  of  the 
fascia  which  covers  the  pectineus  muscle.  Internally,  the  space  is 
bounded  by  the  sharp,  curved  edge  of  Gimbemat's  ligament.  The 
space  is  limited  externally  by  the  junction  of  Poupart's  ligament 
and  the  ilio-pectineal  ligament. 

TJie  Femoral  Slieath. — ^As  the  femoral  vessels  pass  into  the  thigh, 
through  the  femoral  space,  they  are  inclosed  in  a  special  connective- 
tissue  sheath,  and  rest  upon  the  ilio-psoas  and  pectineus  muscles. 
The  femoral  sheath  is  a  funnel-shaped  connective-tissue  envelope 
which  is  prolonged  downward  from  the  margins  of  the  femoral  space, 
inclosing  the  vessels  as  they  pass  into  the  thigh.  Corresponding  to 
its  commencement  at  Poupart's  ligament,  the  femoral  sheath  is  wide- 
mouthed,  and  attached  all  around  to  the  margins  of  the  femoral 
space.  Above,  it  is  attached  to  Poupart's  ligament;  below,  to  the 
ilio-pectineal  ligament  (thickened  portion  of  the  fascia  covering  the 
ilio-psoas  muscle)  and  to  the  ligament  of  Cooper  (thickened  upper 
portion  of  the  fascia  that  covers  the  pectineus  muscle).  Internally, 
it  is  attached  to  the  edge  of  Gimbemat's  ligament.  The  femoral 
sheath  is  continued  but  a  short  distance  downward  upon  the  femoral 
vessels,  becoming  narrow  and  contracted  below,  and  closely  applied 
to  the  walls  of  the  vessels. 

The  femoral  sheath  is  divided  into  three  compartments,  which 
are  entirely  separate  and  distinct  from  each  other,  by  connective- 
tissue    septa.      In   the    outer    compartment    the    femoral    artery    is 


608  HERNIA,  ETC. 

lodged;  in  the  middle,  the  femoral  vein;  the  inner  compartment 
contains  a  lym23hatic  gland  and  some  loose  connective  tissue,  and 
gives  passage  to  the  lymphatic  vessels  that  enter  the  abdomen  from 
the  lower  extremity.  This  space,  the  inner,  is  called  the  crural  canal. 
It  is  inclosed  within  the  femoral  sheath,  and  reaches  from  Gim- 
bernat's  ligament  downward  npon  the  inner  side  of  the  femoral  vein 
as  far  as  the  Junction  of  the  internal  saphenous  vein  with  the  fem- 
oral, at  which  point  the  crural  canal  ceases  to  exist,  because  here  the 
femoral  sheath  is  applied  directly  to  the  wall  of  the  femoral  vein. 

The  orifice  of  this  crural  space,  or  canal,  is  called  the  crural 
ring.  The  crural  ring  is  bounded  above  by  Poupart's  ligament;  be- 
low, by  the  jiectineus  muscle  and  the  fascia  which  covers  it,  and 
which  is  here  thickened  and  called  the  pubic  ligament  of  Cooper; 
internally,  by  Gimbemat's  ligament;  and,  externally,  by  the  femoral 
vein.  A  femoral  hernia,  as  it  descends  into  the  thigh,  usually  oc- 
cupies this  crural  canal,  lying  to  the  inner  side  of  the  femoral  vein, 
and,  just  above  the  junction  of  the  internal  saphenous  vein  with 
the  femoral  vein,  where  the  crural  canal  terminates,  it  presents  in 
the  saphenous  opening. 

Study  of  the  Ingninal  and  Femoral  Regions  from  Within  the 
Abdomen. — To  examine  these  regions  from  within  the  abdomen,  an 
incision  is  made  through  the  anterior  abdominal  wall,  on  either  side, 
passing  from  the  umbilicus  outward  and  then  downward  to  a  point 
just  external  to  the  anterior  superior  spine  of  the  ilium. 

The  Inguinal  Eegion. — The  bladder  is  seen  to  occupy  the  an- 
terior median  portion  of  the  true  pelvis,  and  when  moderately  full 
reaches  as  high  as  the  S3^mphysis.  It  will  be  observed  that  the 
peritoneum  which  covers  the  bladder  is  continued  forward  from  the 
fundus  of  that  organ  over  on  to  the  posterior  surface  of  the  ante- 
rior wall  of  the  abdomen,  where  it  presents  several  folds,  or  ridges, 
which  are  caused  by  the  projection  of  prominent  underlying  struc- 
tures. These  several  ridges,  or  plicae,  converge  in  a  direction  upward, 
toward  the  umbilicus,  and  include  between  them  areas  which  are 
more  or  less  depressed,  and  which  are  called  fovege.  In  the  middle  line, 
reaching  from  the  summit  of  the  bladder  upward  to  the  umbilicus,  the 
peritoneum  is  raised  in  the  shape  of  a  fold  by  the  superior  ligament  of 
the  bladder,  the  remains  of  the  foetal  urachus.  External  to  this,  pass- 
ing from  either  side  of  the  body  of  the  bladder  upward  to  the  um- 
bilicus, there  is  a  fold,  beneath  which  the  obliterated  hypogastric 
arten'  runs.     Still  more,  externally  there  is  another  fold,  which  corre- 


Fig.  273.— The  Pelvis  and  Ligaments  of  the  Ilio-pubic  Region.  FS,  femoral 
space;  G,  Gimbernat's  ligament;  IP,  ilio-pectineal  ligament;  IPS;  ilio-psoas 
space;  P,  Poupart's  ligament;  PS,  pubic  spine. 


Fig.  274. — Femoral  Space.  Femoral  vessels  and  sheath  as  they  pass  under 
Poupart's  ligament  have  been  cleared  away.  Poupart's  ligament  lifted  upon 
hook.  The  iliacus  and  psoas  muscles  are  covered  by  their  fascia,  the  fascia 
iliaca;  IP,  ilio-pectineal  ligament— thickened  portion  of  the  fascia  that  invests 
the  ilio-psoas  muscle;  LP,  Poupart's  ligament;  P,  pubic  ligament  of  Cooper — 
upper  thickened  part  of  the  fascia  that  covers  the  pectineus  muscle. 

39 


610  HERNIA,  ETC. 

sponds  to  the  course  of  the  deep  epigastric  artery ;  this  is  a  large  vessel 
given  off  froni  the  external  iliac  (femoral)  just  before  it  passes  out  of 
the  abdomen  under  Poupart^s  ligament,  and  is  accompanied  by  one  or 
two  veins.  The  peritoneal  folds  are  named,  respectively,  the  plica 
vesico-umbilicalis  media,  corresponding  to  the  urachus,  in  the  middle 
line;  the  plica  vesico-umbilicalis  lateralis,  corresponding  to  the  oblit- 
erated h3^pogastric  artery;  and  the  plica  epigastrica,  corresponding  to 
the  epigastric  artery  and  vein.  Between  these  peritoneal  folds,  or 
plicae,  are  the  fovejfi,  already  mentioned,  which  are  deeper  in  some 
subjects  than  in  others.  External  to  the  plica  epigastrica  is  the  fovea 
inguinalis  externa.  Between  the  plica  epigastrica  and  the  plica  vesico- 
umbilicalis  lateralis  is  the  fovea  inguinalis  interna.  Between  the  plica 
vesico-umbilicalis  lateralis  and  the  plica  vesico-umbilicalis  media  is 
the  fovea  supravesicalis. 

The  Fovea  Inguinalis  Externa. — After  the  peritoneum  has  been 
,  stripped  off  from  this  area,  and  some  loose  connective  tissue  (sub- 
peritoneal connective  tissue)  which  lies  beneath  it  has  been  removed, 
we  expose  the  transversalis  fascia.  This  fascia  presents  the  opening 
into  the  infundibular  process,  the  so-called  "internal  ring,^^  which  is 
located  about  half  an  inch  above  the  middle  of  Poupart's  ligament. 
The  vas  deferens,  spermatic  artery,  veins,  etc.,  structures  of  which 
the  spermatic  cord  is  formed  (in  the  female,  the  round  ligament), 
pass  into  this  opening.  The  lower,  inner,  margin  of  the  internal 
ring  presents  a  distinct,  sharp,  crescentic  edge.  A  probe  or  the  finger 
can  be  introduced  into  the  internal  ring,  and  may  be  insinuated  for 
a  greater  or  less  distance  into  the  sheath  of  the  spermatic  cord, 
infundibular  process.  About  the  internal  ring  the  peritoneum  is 
more  or  less  plaited  upon  itself,  and  is  adherent  to  the  margins  of 
the  ring,  and  may  bulge  for  a  certain  distance  into  it.  A  fibrous 
cord  passes  from  the  peritoneum  into  the  internal  ring,  and  may  be 
traced  downward  into  the  infundibular  process  along  with  the  other 
constituents  of  the  spermatic  cord.  This  fibrous  band,  or  string, 
represents  the  shrunken,  obliterated  vaginal  process  of  peritoneum 
which  accompanies  the  testis  in  its  descent  into  the  scrotum.  Di- 
rected upward  and  inward  toward  the  umbilicus,  and  passing  to  the 
inner  side  of  the  internal  ring,  is  the  deep  epigastric  artery,  with  its 
accompanying  vein.  If  a  hernial  protrusion  occurs  in  this  location, 
the  process  of  peritoneum  which  forms  the  sac  of  the  hernia  forces 
its  way  through  the  internal  ring  (to  the  outer  side  of  the  deep 
epigastric),  and  gradually  works  its  way  downward  within  the  fibrous 


SURGICAL  ANATOMY  OF  THE  GROIN.  ETC. 


611 


Fig.  275.— Deep  Femoral  Region— the  Femoral  Vessels,  etc.,  Cut  Across  as  they 
Emerge  Under  Poupart's  Ligament.  AC,  anterior  crural  nerve;  C'T,  edge  of  the 
conjoined  tendon;  CR,  crural  ring;  E,  dotted  line  indicates  the  course  of  the 
deep  epigastric  artery;  F8,  femoral  sheath;  G,  Gimbernat's  ligament;  IP,  ilio- 
pectineal  ligament;  P,  Poupart's  ligament;  PE,  pectineus  muscle.  This  muscle 
rests  upon  the  pubic  bone  and  is  covered  by  its  fascia, — the  pectineal  fascia, — 
which  is  somewhat  thickened  Immediately  beneath  Poupart's  ligament,  where 
it  is  known  as  the  pubic  ligament  of  Cooper.  It  will  be  noticed  that  the  femoral 
sheath  is  divided  into  three  compartments:  the  outer  for  the  femoral  artery; 
the  middle  for  the  femoral  vein;  the  inner  (CR)  is  the  crural  ring,  the  mouth 
of  the  crural  canal. 


612  HERNIA,  ETC. 

sheath  of  the  cord,  which  is  the  remains  of  the  original  infun- 
dibular process,  and  we  then  have  a  typical  external,  or  oblique, 
inguinal  hernia.  The  coverings  of  this  variety  of  hernia,  from 
within  outward,  are,  besides  its  peritoneal  sac,  the  infundibular  fascia 
(pouch  derived  from  fascia  transversalis),  cremaster  muscle  and  fascia, 
deep  layer  of  the  superficial  fascia  (spermatic  fascia),  superficial  layer 
of  the  superficial  fascia  (fat),  and  the  skin. 

If  a  congenital  hernia  is  present,  the  vaginal  peritoneal  process 
which  accompanied  the  testis  in  its  descent  into  the  scrotum  is  found 
patent,  unobliterated,  reaching  doAvnward  through  the  internal  ring 
and  along  the  cord  within  its  sheath  (infundibular  process)  to  the 
bottom  of  the  scrotum. 

The  coverings  of  a  congenital  hernia  are  the  same  as  those  given 
for  the  oblique,  or  external,  acquired  variety.  The  difference  be- 
tween the  oblique  acquired  and  the  congenital  is  that  the  acquired 
must  form  a  peritoneal  sac  for  itself,  whereas  the  congenital  finds 
its  sac  already  present;  i.e.,  the  unobliterated  vaginal  peritoneal 
process. 

The  Fovea  Inguinalis  Interna. — This  is  the  space  between  the 
plica  epigastrica  and  the  plica  vesico-umbilicalis  lateralis.  After  the 
peritoneum  has  been  stripped  away  from  this  part  we  expose  the  trans- 
versalis fascia.  The  fovea  inguinalis  interna  is  the  part  which  is  in- 
volved in  direct  inguinal  hernia.  It  presents  no  opening.  In  the 
event  of  a  direct  inguinal  hernia,  a  bulging  or  pouching  of  this  part 
of  the  posterior  wall  of  the  inguinal  canal  occurs,  and  the  hernial 
sac,  composed  of  the  parietal  peritoneum,  will  have  as  coverings, 
from  within  outward,  the  various  layers  that  form  this  part  of  the 
posterior  wall  of  the  inguinal  canal,  viz.,  the  fascia  transversalis, 
the  conjoined  tendon,  and  the  triangular  ligament,  and,  in  addition, 
the  deep  la3^er  of  the  superficial  fascia  (spermatic  fascia),  the  super- 
ficial layer  of  the  superficial  fascia  (fat),  and  the  skin. 

The  neck  of  the  sac  in  a  direct  inguinal  hernia  lies  to  the  inner 
side  of  the  deep  epigastric  vessels. 

Fovea  Supravesicalis. — This  is  the  space  between  the  plica 
vesico-umbilicalis  lateralis  and  media.  Its  floor  is  formed  by  the 
rectus  muscle.  This  region  is  of  but  little  surgical  interest,  and  is 
not  the  site  of  hernial  protrusions. 

The  Femoral  Eegion". — Below  Poupart's  ligament  we  have  the 
femoral  region.  This  part  is,  at  times,  depressed,  and  is  called  the 
fossa  cruralis.     If  we  dissect  away  the  peritoneum,  we  expose  Pou- 


Fig.  276. — The  Inguinal  and  Femoral  Regions  from  Within  the  Abdomen. 
Upon  the  right  side  the  peritoneum  has  been  stripped  off,  exposing  the  trans- 
versalis  fascia.  AC,  anterior  crural  nerve  imbedded  in  the  ilio-psoas  muscle;  D, 
semilunar  fold  of  Douglas — the  lower  edge  of  the  posterior  layer  of  the  sheath 
of  rectus;  E,  deep  epigastric  artery;  E^,  plica  epigastrica  (the  deep  epigastric 
vessels  are  situated  beneath  this  foldl ;  F.I.,  cut  edge  of  the  fascia  iliaca,  which 
invests  the  ilio-psoas  muscle;  GL,  Gimbernat's  ligament;  E,  obliterated  hypo- 
gastric artery;  I.E.,  fovea  inguinalis  externa;  /./.,  fovea  inguinalis  interna; 
IL,  sawn  surface  of  the  ilium;  IPL.  ilio-pectineal  ligament,  a  thickened  portion 
of  the  iliac  fascia;  P,  cut  edge  of  the  peritoneum:  P. I.,  cut  edge  of  the  ilio- 
psoas muscle;  PL,  Poupart's  ligament;  Pil,  pectineus  muscle  covered  by  its 
fascia,  which  is  here  somewhat  thickened  and  is  known  as  the  pubic  ligament 
of  Cooper;  SV,  fovea  supravesicalis;  Y.L.,  plica  vesico-umbilicalis  lateralis  (the 
obliterated  hypogastric  artery  lies  beneath  this  fold);  T.J/.,  plica  vesico-umbili- 
calis media  (the  urachus,  which  reaches  from  the  fundus  of  the  bladder  to  the 
umbilicus,  is  situated  beneath  the  fold).  Above  the  middle  of  Poupart's  liga- 
ment there  is  an  opening  in  the  transversalis  fascia — internal  inguinal  ring — 
mouth  of  the  infundibular  process.  The  vas  deferens  and  other  component 
parts  of  the  spermatic  cord  which  pass  in  and  out  of  the  abdomen  through  this 
orifice  have  been  cut  short  in  the  picture;  this  opening  is  the  exit  for  indirect 
inguinal  hernia.  Beneath  Poupart's  ligament  the  femoral  vessels,  inclosed  with 
their  sheath,  are  seen.  These  structures  have  been  divided  close  to  Poupart's 
ligament.  The  femoral  sheath  occupies  the  space  described  as  the  femoral 
space,  and  is  divided  into  three  compartments — the  outer  for  the  artery  and  the 
middle  for  the  vein;  the  orifice  of  the  inner  compartment  is  called  the  crural  ring. 


614  HERNIA,  ETC. 

part's  ligament,  passing  from  the  anterior  superior  spinous  process 
of  the  ilium  inward  and  downward,  to  be  attached  to  the  spine  of 
the  pubes.  From  the  lower  border  of  Poupart's  ligament,  just  be- 
fore its  attachment  to  the  pubic  spine,  a  triangular  band  of  fibers, 
which  is  attached  to  the  ilio-pectineal  line,  is  given  off.  This  is 
called  Gimbemat's;  ligament.  Its  sharp  outer  edge  may  be  readily- 
felt. 

Between  Poupart's  ligament  and  the  pubic  bones  there  is  a  large 
space  through  which  the  ilio-psoas  muscle  and  anterior  crural  nerve 
and  the  femoral  vessels  pass  into  the  thigh.  The  ilio-psoas  muscle 
arises  within  the  abdomen  and  passes  down  toward  Pouparf  s  liga- 
ment in  one  mass,  which  is  invested  by  a  strong  fascia,  the  iliac. 
At  Poupart's  ligament,  the  fascia  that  covers  the  outer  part  of  the 
psoas-iliacus — i.e.,  that  part  of  it  which  corresponds  to  the  outer 
third  of  Poupart's  ligament^ — is  attached  to  Poupart's  ligament,  and 
is  thence  reflected  upward,  becoming  continuous  with  the  transver- 
salis  fascia,  which  lines  the  whole  posterior  surface  of  the  anterior 
abdominal  wall.  Internal  to  this,  however,  where  the  femoral  ves- 
sels pass  out  under  Poupart's  ligament,  the  fascia  is  continued  down- 
ward with  the  muscle  underneath  Poupart's  ligament,  into  the 
thigh.  As  the  femoral  vessels  descend  into  the  thigh  they  rest  upon 
the  pectineus  and  ilio-psoas  muscles,  separated  from  them,  however, 
by  the  fascia  which  covers  them,  the  pectineal  fascia^  covering  the 
pectineus  muscle,  and  the  iliac  fascia  covering  the  ilio-psoas  muscle. 

The  fascia  iliaca,  immediately  beneath  Poupart's  ligament,  is 
thickened,  and  is  called  the  ilio-pectineal  ligament.  It  reaches  from 
the  junction  of  the  outer  and  middle  thirds  of  Poupart's  ligament  to 
the  ilio-pectineal  eminence,  and  serves  to  divide  the  space  under 
Poupart's  ligament . into  two  portions:  that  for  the  ilio-psoas  muscle 
•and  anterior  crural  nerve,  below  and  externally,  and  that  through 
which  the  femoral  vessels  pass,  above  and  internally.  This  latter 
is  called  the  femoral  space.  The  boundaries  of  the  femoral  space 
are,  above,  Poupart's  ligament;  below  and  externally,  the  ilio-pec- 
tineal ligament  (thickened  portion  of  the  iliac  fascia)  ;  below  and 
internally,  the  pubic  ligament  of  Cooper  (the  upper  thickened  por- 
tion of  the  fascia  that  covers  the  pectineus  muscle)  ;  internally,  the 
edge  of  Gimbernat's  ligament. 

As  the  femoral  vessels  pass   down  through   the   femoral   space 


1  That  part  of  the  pubic  portion  of  the  fascia  lata  that  covers  the  pectineus  muscle. 


OPERATIONS  FOR  HERNIA.  615 

into  the  thigh,  they  are  inclosed  in  a  connective-tissue  sheath,  which 
is  prolonged  downward  from  the  margins  of  this  space.  It  is  called 
the  femoral  sheath.  The  femoral  sheath  is  divided  into  three  com- 
partments by  septa:  the  outer  contains  the  artery;  the  middle  one, 
the  vein;  the  innermost,  that  between  the  vein  and  the  edge  of 
Gimbernat's  ligament,  is  the  so-called  crural  canal,  and  gives  pas- 
sage to  lymphatics  from  the  thigh  to  the  abdomen.  The  abdominal 
orifice  of  the  crural  canal  is  called  the  crural  ring. 

In  the  event  of  a  femoral  hernia,  a  process  of  peritoneum  (her- 
nial sac)  is  forced  into  the  crural  ring  and  down  through  the  crural 
canal,  appearing  below  in  the  upper  part  of  the  thigh  in  the  saphe- 
nous opening. 

The  coverings  of  a  femoral  hernia,  from  within  outward,  are, 
besides  its  peritoneal  sac,  the  femoral  sheath,  the  deep  layer  of  the 
superficial  fascia  (the  cribriform  fascia),  the  superficial  layer  of  the 
superficial  fascia  (fat),  and  the  skin. 

The  Obturator  Foramen. — This  foramen  is  located  below  the 
brim  of  the  pelvis.  It  is  an  opening  in  the  upper  part  of  the  ob- 
turator membrane,  between  its  upper  edge  and  the  lower  border  of 
the  ramus  of  the  pubes.  This  foramen  gives  exit  to  the  obturator 
artery,  vein,  and  nerve,  and  is  sometimes  the  site  of  a  hernial  protru- 
sion. The  obturator  artery  usually  arises  from  the  external  iliac, 
passes  forward  just  below  the  brim  of  the  pelvis,  and  out  through 
the  obturator  foramen  into  the  thigh.  Occasionally,  however,  this 
artery  is  derived  from  the  deep  epigastric,  close  to  the  origin  of  thia 
vessel  from  the  external  iliac  (femoral),  and  in  its  course  to  reach 
the  obturator  foramen  it  is  found  in  close  proximity  to"  the  margin 
of  the  crural  ring.  After  its  origin  from  the  deep  epigastric,  in  its 
course  to  reach  the  obturator  foramen,  it  either  passes  around  the 
upper  and  inner  margins  of  the  crural  ring  or  else  it  descends  close 
to  the  inner  wall  of  the  femoral  vein  and  behind  the  outer  border  of 
the  crural  ring. 

OPERATIONS  FOR  HERNIA. 

Hemiotomy. — Incision  of  the  coverings  of  a  hernia,  opening 
into  the  sac,  and  the  division  of  constricting  rings  or  bands  constitute 
the  operation  of  herniotomy.  The  operation  is  done  for  the  purpose 
of  liberating  a  strangulated  hernia.  The  constriction  may  be  caused 
by  bands  in  the  body  of  the  sac  or  by  the  neck  of  the  sac  itself,  but  in 


616 


HERNIA,  ETC. 


most  cases  it  is  probably  caused  by  the  firm,  unyielding  ring  by  whicli 
the  neck  of  the  sac  is  encircled. 

At  one  of  the  usual  sites  of  a  hernial  protrusion  there  is  found  a 
tense,  elastic  tumor.  The  incision  is  placed  over  the  most  prominent 
part  of  the  tumor,  cutting  carefully  through  the  skin  and  the  deeper 
layers  until  the  sac  proper  is  reached.  The  sac  may  then  be  pinched 
up  with  two  forceps  and  incised  between  them,  when  there  is  an 
escape  of  serous  fluid,  and  the  contents  of  the  sac  are  exposed. 


Fig.  277. — Irregular  Origin  of  Obturator  Artery.  In  its  course  into  the  pelvis 
it  lies  close  to  the  inner  side  of  the  femoral  vein.  A,  femoral  artery;  E,  deep 
epigastric  artery;  GL,  Gimbernat's  ligament;  IR,  internal  inguinal  ring;  0, 
obturator  artery;  PL,  Poupart's  ligament;  Y,  femoral  vein.  The  space  between 
the  femoral  vein  and  Gimbernat's  ligament  is  known  as  the  crural  ring,  and 
through  this  femoral  hernia  leaves  the  abdomen. 


The  contents  vary;  they  may  consist  of  intestine,  large  or  small; 
of  omentum,  or  of  both ;  and  occasionally  there  may  be  other  organs, 
such  as  the  bladder,  ovary,  etc.  After  the  sac  has  been  freely 
opened,  its  contents  should  be  examined.  Any  constricting  bands  in 
the  body  of  the  sac  should  be  divided,  and  an  attempt  then  made  to 
pull  the  gut  down  so  as  to  ease  it  at  the  point  of  constriction;  but 
in  this  effort  much  force  should  not  be  used.    An  effort  is  made  to 


OPERATIONS  FOR  HERNIA. 


617 


insert  the  finger  into  the  neck  of  the  sac,  and,  if  this  is  successful,  a 
probe-pointed,  curved  knife  may  be  introduced  upon  the  finger  and 
the  constricting  ring  incised.  If  one  is  unable  to  insert  the  finger 
into  the  neck  of  the  sac,  a  director  may  be  carried  through,  and  upon 
this  the  ring  may  be  divided.  In  freeing  the  constriction,  a  suc- 
cession of  nicks  should  be  made  rather  than  a  single  free  cut,  and 
these  may  be  repeated  until  the  parts  are  liberated. 

For  the  relief  of  an  indirect  inguinal  hernia  the  incision  in  the 


Fig.  278. — Irregular  Origin  of  Obturator  Artery.  In  its  course  into  the  pelvis 
it  curves  around  the  upper  and  inner  edge  of  the  crural  ring.  Letters  same 
as  277. 


constricting  ring  should  be  directed  upward.  For  a  direct  inguinal 
hernia  the  incision  should  be  directed  upward  and  inward,  toward 
the  umbilicus.  For  a  femoral  hernia  the  incision  should  be  directed 
inward  toward  Gimbemat's  ligament  and  somewhat  upward. 

For  practical  purposes,  if  in  doubt  as  to  the  exact  variety  of  the 
hernia,  the  direction  of  the  liberating  incision  for  both  varieties  of 
inguinal  and  for  femoral  hernia  may  be  upward  and  inward,  toward 
the  umbilicus.     By  cutting  in  this   direction,  upward   and   inward, 


Qlg  HERNIA,  ETC. 

toward  the  Timbilieus,  we  work  in  a  line  which  is  parallel  with  the 
course  of  the  deep  epigastric  vessels,  and  the  danger  of  wounding 
these  is  thus  obviated. 

Occasionally  the  obturator  artery,  as  described  above,  is  given 
off  from  the  deep  epigastric,  and  in  its  course  to  reach  the  obturator 
foramen  this  vessel  would  then  have  a  close  relationship  to  the  neck 
of  the  sac  of  a  femoral  hernia.  From  its  origin,  at  the  deep  epigas- 
tric, the  obturator  artery  either  descends  close  to  the  inner  wall  of 
the  femoral  vein,  and  therefore  behind  the  outer  margin  of  the  crural 
ring,  and  would  thus  lie  to  the  outer  side  of  the  neck  of  a  femoral  her- 
nial sac,  or  else  it  curves  inward  and  then  downward,  behind  the  up- 
per and  inner  borders  of  the  crural  ring,  and  would  then  lie  above  and 
to  the  inner  side  of  a  femoral  hernial  sac.  In  the  first  case,  this  ves- 
sel would  be  out  of  the  way  in  making  the  liberating  incisions  at 
the  crural  ring,  whereas  in  the  second  instance  the  vessel  would  be 
jeopardized  in  making  the  liberating  incisions  if  caution  were  not  exer- 
cised. 

If  the  constriction  at  the  neck  of  the  sac  is  relieved  by  a 
succession  of  nicks,  rather  than  by  a  single  free  incision,  we  will 
be  very  much  less  liable  to  divide  an  abnormally  placed  obturator 
artery.  After  the  contents  of  the  sac  have  been  liberated  they  may 
be  drawn  down  for  examination,  especially  at  the  points  of  constric- 
tion. If  omentum  is  present,  this  may  be  ligated  and  amputated. 
As  to  the  treatment  of  the  gut,  careful  deliberation  must  be  used. 
If  the  gut  is  healthy,  it  may  be  returned  at  once  into  the  abdomen. 
If  doubtful,  one  may  wait  for  a  short  time  to  note  if  it  tends  to  clear 
up.  After  the  gut  has  been  reduced  the  finger  should  be  introduced 
through  the  neck  of  the  sac  in  order  to  make  certain  that  there  are 
no  adhesions  about  the  neck  which  might  continue  to  constrict  the 
gut. 

If  the  gut  is  gangrenous,  or  too  doubtful  to  return  into  the  ab- 
domen, the  incision  in  the  abdomen  at  the  neck  of  the  sac  should 
be  enlarged  and  the  gut  drawn  down  and  resected;  or  else  the  gut 
may  be  allowed  to  remain  without  disturbing  the  adhesions  about  the 
neck  of  the  sac,  and  an  artificial  anus  made  by  incising  the  strangu- 
lated coil  of  gut,  if  it  has  not  already  sloughed  through.  The  wound, 
under  these  circumstances,  should  be  left  open  and  packed. 

Radical  Operation  for  Inguinal  Hernia  (Bassini  Method).  For 
AN  Oblique  Acquired  Hernia. — An  incision  is  made  through  the 
skin,  commencing  at  a  point  half  an  inch  above  and  somewhat  ex- 


OPERATIONS  FOR  HERNIA. 


619 


ternal  to  the  middle  of  Poupart's  ligament,  carrying  it  downward 
and  inward  as  far  as  the  spine  of  the  pubes ;  or  it  may  be  prolonged 
for  a  short  distance  downward  upon  the  scrotum,  if  necessary.  Thib 
incision  penetrates  into  the  subcutaneous  fatty  layer.  In  its  upper 
part  the  incision  should  be  deepened  until  the  fibers  of  the  aponeu- 
rosis of  the  external  oblique  are  plainly  visible.  The  fingers  are 
then  introduced  into  this  upper,  deeper  part  of  the  incision,  and  it 


Fig.  279. — Operation  for  Inguinal  Hernia.  Incision  penetrates  through  the 
skin  and  fat,  exposing  the  aponeurosis  of  the  external  oblique.  SC,  spermatic 
cord  emerging  from  the  external  inguinal  ring. 


is  torn  open  down  to  its  lower  end.  After  this  has  been  done  the 
apenourosis  of  the  external  oblique  and  the  pillars  of  the  external 
ring,  through  which  the  cord  emerges,  are  exposed. 

Any  bleeding  points  are  caught  in  artery  forceps;  but  it  is  not 
necessary  to  ligate  them  immediately,  as  the  hemorrhage  usually 
ceases  after  a  few  minutes'  compression. 

A  blunt  director  is  now  passed  into  the  external  ring,  and  car- 


620  HERNIA,  ETC. 

ried  upward  and  outward  beneath  the  aponeurosis  of  the  external 
oblique  to  a  point  beyond  the  middle  of  Poupart's  ligament,  the 
location  of  the  "internal  ring/'  and  upon  this  the  aponeurosis  is 
divided.  Some  obstruction  to  the  introduction  of  the  director 
through  the  external  ring  will  be  experienced  if  the  deep  layer  of  the 
superficial  fascia,  which  is  attached  to  the  margins  of  the  ring,  has 
not  been  incised. 

The  edges  of  the  split  aponeurosis  of  the  external  oblique  are 
seized  with  artery  forceps  and  separated  with  the  finger  from  the 
structures  which  lie  immediately  beneath.  The  inguinal  canal  is 
■  thus  laid  open,  and  the  spermatic  cord,  together  with  the  hernial 
sac,  is  exposed.  The  lower,  free  fleshy  edge  of  the  internal  oblique 
muscle  is  seen  arching  inward  over  the  cord  and  hernial  sac.  It  is 
blended  with  the  tendon  of  the  transversalis  muscle  to  form  the  con- 
joined tendon,  which  descends  behind  the  cord,  and  which  can  be  felt 
as  a  strong,  resistant  band  attached  to  the  crest  of  the  pubic  bone. 

The  spermatic  cord,  together  with  the  hernial  sac,  which  is 
usually  found  empty  unless  its  contents  are  irreducible  or  the  pa- 
tient is  straining,  is  now  hooked  up,  upon  the  finger,  and  we  proceed 
to  separate  the  sac  from  the  cord.  At  times  it  is  difficult  to  recog- 
nize the  sac.  It  is  formed  of  the  pouch  of  peritoneum,  with  some 
loose  connective  tissue  (subperitoneal  connective-tissue  layer)  and 
is  situated  within  the  proper  sheath  of  the  spermatic  cord  (infundib- 
ular process  of  transversalis  fascia),  which  must  be  incised  or  torn  in 
order  to  expose  it  (the  sac) .  The  sac  has  a  peculiar,  white,  aponeurotic 
appearance,  and  may  be  very  thin  or  of  moderate  thickness.  The  isola- 
tion of  the  sac  from  the  cord  is  accomplished  chiefly  by  tearing  and 
separating  with  the  fingers,  occasionally  cutting  a  resisting  band  with 
the  scissors.  At  times  the  sac  is  very  intimately  united  with  the 
cord,  and  much  patience  is  required  to  separate  it.  One  should 
recognize  the  vas  deferens,  and  constantly  be  familiar  with  its  loca- 
tion, in  order  to  avoid  injuring  it.  In  isolating  the  sac,  one  may 
have  considerable  hemorrhage  from  the  pampiniform  plexus  of  veins, 
which  runs  along  with  the  vas  deferens,  etc.,  in  the  cord.  It  usually 
ceases,  however,  after  clamps  have  been,  applied  to  the  bleeding 
points  for  a  few  minutes.  If  one  of  the  arterial  branches  which  run 
in  the  cord  is  torn,  it  will  be  necessary  to  apply  a  ligature.  One  may 
begin  the  separation  of  the  sac  from  the  cord  above  at  the  neck  of 
the  sac  and  work  downward,  toward  its  lower  part  (fundus),  or 
commence  at  the  fundus  and  work  upward,  toward  the  neck.     The 


OPERATIONS  FOE  HERNIA. 


621 


Fig.  280. — Bassini  Operation  for  Inguinal  Hernia.  The  inguinal  canal  laid 
open  by  splitting  the  aponeurosis  of  the  external  oblique.  The  edges  of  the 
split  aponeurosis  seized  with  artery  forceps  and  drawn  aside.  Spermatic  cord 
retracted  with  a  loop  of  silk.  The  hernia  sac,  unopened,  has  been  detached 
from  the  spermatic  cord  and  reflected  upward  and  outward;  C.T.,  edge  of 
conjoined  tendon;  P.,  edge  of  Poupart's  ligament;  T.F.,  transversalis  fascia 
which  forms  the  posterior  wall  of  the  inguinal  canal. 


623  HERNIA,  ETC. 

operator  raay  assist  himself  in  separating  the  sac  from  the  cord  by 
incising  it  in  order  to  introduce  the  finger  into  it,  and  thus  inform 
himself  of  its  limits. 

After  the  sac  has  been  completely  separated  from  the  cord,  espe- 
cially above,  about  the  neck  at  the  location  of  the  "internal  ring,^' 
it  is  raised,  and  (if  not  already  incised)  is  seized  by  an  assistant  with 
the  fingers  of  both  hands,  or  with  two  artery  forceps,  and  incised 
between  them  with  the  knife.  In  incising  the  sac,  especially  if  the 
contents  are  adherent,  or  if  operating  upon  a  strangulated  hernia 
when  there  is  much  distension,  one  should  use  caution  not  to  wound 
the  parts  within.  After  the  sac  has  been  opened  the  contents  may 
be  reduced,  and,  if  there  are  no  adhesions,  this  is  very  readily  done. 
If  there  is  a  considerable  amount  of  prolapsed  omentum  in  the  sac, 
this  may  be  tied  off  with  stout  catgut  and  amputated  in  preference 
to  returning  it  to  the  abdomen.  If  the  contents  are  adherent  to  the 
sac,  they  must  be  gently  separated  before  they  can  be  reduced.  This 
can  usually  be  accomplished  with  the  finger,  taking  care  to  avoid 
tearing  the  gut,  and  ligating  any  points  that  bleed  freely.  Dense 
adhesion  bands  may  be  first  tied  double  and  then  divided  between 
the  ligatures.  If  omentum  is  adherent  within  the  sac,  it  may  be 
ligated  and  amputated.  The  contents  should  be  free,  especially  at 
the  neck  of  the  sac,  in  order  that  they  may  be  properly  reduced. 

After  the  sac  has  been  emptied  we  may  tie  it  off.  The  finger  is 
introduced  into  the  sac  and  carried  well  within  its  mouth,  and  a  catgut 
ligature  (No.  2)  thrown  around  its  neck.  As  this  ligature  is  drawn 
tight  and  tied,  one  should  feel  it  slip  over  the  end  of  the  finger, 
which  is  within  the  mouth  of  the  sac.  It  should  be  applied  about 
the  neck  of  the  sac  as  high  up  as  possible,  in  order  to  avoid  leaving 
any  pouched  portion  of  the  sac  to  invite,  the  recurrence  of  the  her- 
nia. The  ligature  is  left  long  for  use  as  a  tractor,  and  the  sac  is  cut 
away,  about  one-fourth  inch  distal  from  the  ligature.  Then,  after 
a  final  examination  of  the  stump  of  the  sac,  the  ends  of  the  ligature 
are  cut  short,  and  the  stump  of  the  sac  allowed  to  retract  into  the 
abdomen.  If  the  sac  is  rather  wide-mouthed,  instead  of  simply 
surrounding  it  with  a  ligature  one  may  transfix  it  with  a  ligature 
carried  in  a  curved  needle  and  tie  double. 

The  next  step  in  the  operation  m  the  strengthening  of  the  poste- 
rior wall  of  the  inguinal  canal,  and  this  is  done  by  approximating 
the  free  edge  of  the  internal  oblique  and  transversalis  muscles  (con- 
joined tendon)   above  to   Poupart's  ligament  below.     While  this  is 


OPERATIONS  FOR  HERNIA. 


623 


Fig.  281.— The  Bassini  Operation.  The  edges  of  the  split  aponeurosis  held 
aside  with  artery  forceps.  Conjoined  tendon  sutured  to  the  edge  of  Poupart's. 
Spermatic  cord  (C.8.)  drawn  aside  with  a  tractor. 


624  HERNIA,  ETC. 

being  done  the  spermatic  cord  is  held  out  of  the  way  of  the  operator 
upon  a  strip  of  gauze,  and  the  upper  edge  of  the  divided  aponeurosis 
of  the  external  oblique,  which  is  held  in  an  artery  forceps,  is  re- 
tracted, in  order  that  the  edge  of  the  internal  oblique  and  trans- 
versalis  (conjoined  tendon)  may  be  made  out.  These  parts  can  be 
readily  seen  and  may  be  plainly  felt  by  the  finger  in  the  wound. 
Poupart's  ligament  is  likewise  freely  exposed,  when  the  lower  edge 
of  the  aponeurosis  of  the  external  oblique  is  strongly  retracted.  This 
structure  may  be  recognized  as  a  sharp,  white  band.  These  parts, 
the  conjoined  tendon  above  and  Poupart's  ligament  below,  are  now 
brought  together  with  three  to  five  interrupted  sutures  of  some  per- 
manent material,  such  as  silk,  silver  wire  or  kangaroo  tendon — kan- 
garoo tendon  is  the  most  satisfactory  material.  These  sutures  are 
introduced  with  a  large,  curved  needle  grasped  in  a  needle  holder. 
The  first  suture  is  placed  externally,  just  to  the  inner  side  of  where 
the  cord  emerges  from  the  abdomen;  the  last  one  or  two  sutures, 
those  nearest  the  middle  line,  should  take  a  sufficiently  broad  bite  to 
include,  together  with  the  conjoined  tendon,  the  edge  of  the  rectus 
muscle.  Each  suture  should  take  a  good,  broad  bite.  In  introducing 
the  sutures  through  Poupart's  ligament  there  is  said  to  be  some 
danger,  especially  with  the  middle  sutures,  of  piercing  the  femoral 
vein  with  the  needle.  This  might  happen  if  the  needle  were  inserted 
too  deeply,  but  this  is  not  necessary,  as  a  good,  broad  bite  of  the  liga- 
ment is  easily  secured  without  introducing  the  needle  deep  enough 
to  reach  the  vein.  The  sutures  are  left  long,  and  are  not  tied  until 
all  are  introduced.  Usually  three  or  four  sutures  suffice;,  sometimes 
live  are  necessary.  The  most  external  suture  is  the  most  important 
and  should  be  placed  so  as  to  leave  just  space  enough  for  the  cord  to 
emerge  comfortably  without  constriction  between  the  edge  of  the 
internal  oblique  and  transversalis  above  and  Poupart's  ligament  below. 
When  the  sutures  are  tied,  the  edge  of  the  internal  oblique  and  trans- 
versalis muscles  (conjoined  tendon)  and  Poupart's  ligament  are  seen 
to  be  closely  approximated,  and  in  this  way  there  is  formed  a  solid 
posterior  wall  to  the  inguinal  canal,  upon  which  the  cord  rests  when  it 
is  dropped  back  into  the  wound.  The  edges  of  the  split  aponeurosis  of 
the  external  oblique  are  now  brought  together  over  the  cord  with  a  con- 
tinuous suture  of  catgut,  simple  or  chromicized,  No.  2.  This  suture 
is  commenced  above  and  externally,  and  terminates  below  at  the  site 
of  the  former  external  abdominal  ring.  In  this  way  the  anterior  wall 
of  the  inguinal  canal  is  restored,  and  beneath  this  the  cord  is  situ- 


OPERATIONS  FOR  HERNIA.  G25 

ated.  One  should  take  care  that  the  cord  is  not  gripped  too  tiglitly 
between  the  posterior  and  anterior  walls  of  the  new  canal,  and  that, 
at  the  site  of  the  external  ring,  sufficient  space  is  .left  for  the  cord 
to  emerge  without  danger  of  its  becoming  strangulated. 

The  wound  should  be  dry— free  from  oozing.  Ko  drainage  is 
necessary.  The  incision  in  the  skin  may  be  closed  with  a  continuous 
intracuticular  catgut  suture. 

In  the  female  this  operation  is  simplified  in  that  we  have  no 
spermatic  cord  to  consider;  the  round  ligament,  its  analogue,  is  sim- 
ply cut  away,  and  the  deep  sutures  which  strengthen  the  posterior 
wall  of  the  inguinal  canal  introdnced  in  the  manner  described  above. 
For  a  Congenital  Hernia. — In  this  variety  of  hernia  the  sac 
is  formed  of  the  unobliterated  vaginal  process  of  the  peritoneum,  at 
the  bottom  of  which  the  testis  usually  lies.     In  some  cases  the  testis 
does  not  reach  the  bottom  of  the  scrotum  in  its  descent,  and  may 
remain  stationary,  in  any  part  of  the  inguinal  canal  or  within  the 
abdomen,  when  it  may  be  wise  to  remove  it.     The  incision  in  the 
skin  and  aponeurosis  of  the  external  oblique  are  made  as  in  the  fore- 
going operation.     After  the  inguinal  canal  has  been  laid  open,  the 
cord,  together  with  the  sac,  is  picked  up,  upon  the  finger.     The  her- 
nial sac  is  really  included  within  the  proper  sheath  of  the  cord,  in- 
fundibular process,  and  its  isolation  from  the  elements  of  the  cord 
may  be  somewhat  difficult.     The  sheath  of  the  cord    (infundibular 
process  of  the  transversalis  fascia)   must  be  incised  or  torn  through, 
in  order  to  reach  the  sac.     In  separating  the  sac  we  may  commence 
above  at  the  neck  of  the  sac,  and  work  downward,  toward  the  testis. 
After  the  sac  has  been  separated  from  the  cord,  vas  deferens,  etc.,  to 
a  point  which  is  just  above  the  testis,  it  is  opened  and  its  contents 
reduced.     The  sac  is  then  cut  across,  allowing  the  lower  part,  thai 
which  corresponds  to  the  testis,  to  remain  to  form  the  tunica  vag- 
inalis.    The  upper  part  of  the  sac,  after  having  been  thoroughly  iso- 
lated, is  then  tied  off  at  the  point  where  it  emerges  from  the  abdo- 
men, and  the  edge  of  the  internal  oblique   and  transversalis    (con- 
Joined  tendon)    sutured  to  Pouparfs  ligament,  as  already  described 
in  the  preceding  operation.     The  lower  part  of  the  vaginal  process 
(hernial  sac)    which  remains,  and  which   corresponds  to  the  tunica 
vaginalis  testis,  is  then  closed  with  a  continuous  catgut  suture,   so 
that  the  testis  is  shut  up  within  its  tunica  vaginalis.     The  edges  of 
the  split  aponeurosis  of  the  external  oblique  are  then  brought  together 
over  the   cord,   and  the   incision  in   the  skin   closed.      If   the   testis 


626  .       HERNIA,  ETC. 

has  been  much  handled,  it  may  be  wise  to  introduce  a  thin 
strip  of  gauze  into  the  cavity  of  the  tunica  vaginalis,  through  the 
bottom  of  the  scrotum,  for  the  purpose  of  drainage;  usually,  how- 
ever, this  is  not  necessary. 

Foe  a  Direct  Inguiistal  Hernia. — In  this  variety  of  hernia  the 
peritoneal  pouch  (hernial  sac)  does  not  enter  the  "internal  ring,'' 
mouth  of  the  infundibular  process,  and  work  its  way  down  along  the 
cord,  within  the  sheath  of  the  cord,  but  bulges  directly  forward,  into 
the  inguinal  canal,  to  the  inner  side  of  the  deep  epigastric  artery, 
pushing  the  transversalis  fascia,  conjoined  tendon^  and  triangular 
ligament  before  it,  and  is  foimd  upon  the  inner  side  of  the  spermatic 
cord  as  this  descends  through  the  inguinal  canal.  The  sac  consists 
of  a  wide-mouthed  pouch  of  peritoneum  and  subperitoneal  connect- 
ive tissue,  and,  as  it  presents  into  the  inguinal  canal,  is  covered 
by  the  transversalis  fascia,  the  conjoined  tendon,  and  the  triangular 
ligament.  It  is  also  covered  by  the  aponeurosis  of  the  external 
oblique,  superficial  and  deep  layers  of  the  superficial  fascia,  and  the 
skin.  The  mouth  of  the  sac  is  wide,  and  may  reach  from  the  external 
edge  of  the  rectus  as  far  outw^ard  as  the  deep  epigastric  artery,  or 
even  beyond  this,  pushing  the  artery  in  front  of  it,  in  which  case 
the  artery  may  form  a  deep  groove  upon  the  sac,  and  thus  divide  it 
into  two  pouches.  Under  these  circumstances  it  may  be  necessary  to 
tie  the  .artery  double  and  divide  it.  There  may  be  no  well-formed 
sac  present,  but  simply  a  wide,  conical  bulging  of  the  posterior  wall 
of  the  inguinal  canal.  In  direct  hernia  the  sac  is  readily  separated 
from  the  cord,  after  which  it  is  opened  and  its  contents  reduced.  If 
the  sac  is  very  wide-mouthed,  it  may  be  necessary  to  approximate  the 
margins  of  the  opening  with' a  catgut  suture,  and  then  cut  away  what 
remains  of  the  sac.  The  operation  is  completed  as  described  above  f oi 
the  oblique  variety.  While  the  cord  is  held  aside,  the  edge  of  the  con- 
joined tendon  (internal  oblique  and  transversalis  muscles)  is  sutured  to 
Poupart's  ligament.  The  cord  is  then  replaced  and  the  edges  of  the 
aponeurosis  of  the  external  oblique  sutured  over  it,  and  finally  the 
incision  in  the  skin  closed. 

Halsted's  Operation  for  Inguinal  Hernia.— The  incision  reaches 
from  a  point  5  cm.  above  and  external  to  the  site  of  the  internal 
ring,  which  is  located  half  an  inch  above  the  middle  of  Poupart's 
ligament.  It  is  carried  downward  and  inward  as  far  as  the  spine  of 
the  pubes  (site  of  the  external  ring).  This  incision  extends  through 
the  skin  and  superficial  fascia,  freely  exposing  the  aponeurosis  of 


OPERATION'S  FOR  HERNIA.  627 

the  external  oblique  muscle  and  the  extci-iial  inguinal  ring.  All 
bleeding  points  are  clamped.  As  a  rule,  it  is  not  necessary  to  tie 
them,  as  the  hemorrhage  ceases  after  a  few  minutes'  compression. 

The  next  step  in  the  operation  consists  in  the  division  of  the 
aponeurosis  of  the  external  oblique,  the  internal  oblique  and  trans- 
versalis  muscles,  and  the  transversalis  fascia.  These  structures  are 
incised  from  the  external  ring  bolow  to  a  point  about  2  cm.  above 
and  external  to  the  location  of  the  internal  ring,  or  farther  if  neces- 
sary, in  order  that  the  upper  and  outer  part  of  the  incision  may  ex- 
tend into  the  fleshy  part  of  the  internal  oblique  and  transversalis 
muscles.  The  vas  deferens  ig  now  sought,  and  together  with  its 
vessels,  isolated,  and  then  all  the  veins  which  accompany  the  vas 
deferens  except  two  or  three,  after  being  tied  off  above  and  below, 
are  excised.  In  this  way  the  size  of  the  cord  is  markedly  dimin- 
ished. The  remains  of  the  cord  are  now  held  to  one  side,  and  the 
isolation  of  the  hernial  sac  is  begun.  After  this  has  been  completed, 
the  sac  is  incised  and  its  contents  returned  into  the  abdomen.  When 
the  transversalis  fascia  is  incised  the  constriction  about  the  neck  of 
the  sac  disappears,  and  its  mouth,  from  a  narrow  orifice,  becomes  a 
wide-open  space,  through  which  one  may  easily  introduce  several 
fingers  or  the  whole  hand  into  the  peritoneal  cavity.  The  margins 
of  the  mouth  of  the  sac  are  now  brought  together  with  a  continuous 
or  interrupted  suture  of  catgut,  and  the  sac  below  this  suture  line 
resected.  This  step  of  the  operation  is  really  like  closing  any  ordi- 
nary opening  in  the  parietal  peritoneum.  During  the  application  of 
this  suture  a  gauze  pad  may  be  introduced,  through  the  opening  into 
the  peritoneal  cavity,  to  prevent  the  intestine  from  prolapsing  into 
the  wound.  After  the  mouth  of  the  sac  (peritoneum)  has  been  thus 
sutured  and  closed,  and  the  sac  cut  away,  we  proceed  with  the  next 
step  of  the  operation,  the  approximation  of  the  cut  edges  of  the 
several  layers  of  the  abdominal  wall.  While  this  is  being  accom- 
plished the  cord  is  raised  upon  a  hook  and  held  out  of  the  way,  well 
toward  the  outer  part  of  the  incision.  To  unite  these  parts  from  six 
to  eighteen  mattress  sutures  of  silk  are  required.  The  layers  which  are 
approximated  consist  above  of  the  aponeurosis  of  the  external 
oblique,  the  internal  oblique  and  the  transversalis  muscles  (con- 
joined tendon),  and  the  transversalis  fascia.  Below  they  consist  of 
Poupart's  ligament  and  the  aponeurosis  of  the  external  oblique  and 
the  transversalis  fascia,  and  in  part,  externally,  of  the  cut  edges  of 
the   internal   oblique   and   transversalis   muscles.      The   sutures    pass 


628 


HERNIA,  ETC. 


through  all  these  laj^'ers.  Between  the  two  most  external  of  these 
sutures  the  cord  emerges  through  the  abdominal  wall^  between  the  cut 
edges  of  the  internal  oblique  and  transversalis  muscles.  ■  The  cord 
sliould   be   firmly   grasped  by  these   muscles,   but  not  tight   enough 


I 


Fig.  282. — Halsted's  Operation.  The  vas  deferens,  with  a  few  remaining 
vessels  of  the  cord,  drawn  aside  with  a  hook.  Mattress  sutures  have  been 
applied,  uniting  the  different  layers  that  have  been  cut,  including  the  apo- 
neurosis of  the  external  oblique. 


to  strangle  it.  The  cord,  as  it  emerges  through  the  abdominal  wall, 
in  its  new  position,  should  be  surrounded  by  the  fleshy  fibers  of  these 
muscles;  it  should  not  emerge  between  the  tendinous  portions  of 
the  muscles.     If  the  incision  through  the  internal  oblique  and  trans- 


OrEKATlU:NS  FOR  HERNIA.  629 

versalis  muscles  and  tlie  transverfalis  fascia  has  not  been  carried 
sufficiently  far,  in  a  direction  upward  and  outward,  to  accomplisli 
this,  it  should  be  extended  farther,  so  as  to  rcadi  well  into  the  fleshy 
portion  of  these  muscles. 

After  the  mattress  sutures  have  been  applied  and  the  parts  al- 
ready mentioned  approximated,  the  cord  is  dropped  back  into  the 
wound  and  rests  upon  the  aponeurosis  of  the  external  oblique.  The 
edges  of  the  skin  are  then  sutured  over  the  cord  with  a  continuous 
intracuticular  suture,  thus  completing  the  operation.  The  cord  i> 
transnlanted  so  that  it  emerges  through  the  abdominal  wall  above 
and  external  to  the  site  of  the  "internal  ring,"  where  it  is  surrounded 
l)y  muscular  fibers  and  lies  just  beneath  the  skin,  instead  of  beneath 
the  a]:!oneurosis  of  the  external  oblique. 

Operation  for  the  Radical  Cure  of  Femoral  Hernia. — ^Femoral 
hernia  descends  through  the  crural  canal  upon  the  inner  side  of  the 
femoral  vein,  and  presents  in  the  thigh,  just  below  Pouparfs  liga- 
ment. In  order  to  expose  the  sac  of  the  hernia  an  incision  is  made 
below  and  parallel  with  Pouparfs  ligament,  the  middle  of  the  in- 
cision being  over  the  center  of  the  tumor.  This  incision  is  carried 
through  the  skin  and  subcutaneous  fatty  tissue  and  the  deep  layer 
of  the  superficial  fascia  (cribriform)  down  to  the  sac.  Instead  of 
being  placed  parallel  with  Pouparfs  ligament,  the  incision  may  be 
made  in  an  oblique  direction  from  above  downward. 

The  sac  is  now  isolated,  and  separated  from  the  adjoining  parts 
up  to  and  beyond  the  level  of  Pouparfs  ligament.  Special  care  is 
required  in  separating  the  sac  on  the  side  which  adjoins  the  femoral 
vein.  After  the  sac  has  been  thoroughly  isolated  it  is  opened  and 
the  contents  reduced.  The  sac  is  then  twisted  and  tied  off  as  high  up 
as  possible.  It  may  be  surrounded  with  a  simple  catgut  ligature,  or 
it  may  be  transfixed  and  tied  double.  The  portion  of  the  sac  below 
the  ligature  is  then  cut  away,  the  ends  of  the  ligature  cut  short,  and 
the  stump  of  the  sac  pushed  back  beyond  Pouparfs  ligament  into 
the  abdomen. 

"We  are  now  ready  to  close  the  orifice  through  which  the  hernia 
descended  into  the  thigh.  We  should  first  recognize  the  margins  of 
this  orifice,  the  crural  ring.  This  is  bounded  above  by  Pouparfs 
ligament;  internally  by  the  edge  of  Gimbernafs  ligament;  below 
by  the  fascia  that  covers  the  pectineus  muscle,  the  upper,  thickened 
portion  of  which  is  called  the  pubic  ligament  of  Cooper,  and  which  ex- 
tends from  Gimbernafs  ligament  to  the  pectineal  eminence ;  externally 


630  HERNIA,  ETC. 

it  is  bounded  by  the  femoral  vein.  The  edge  of  the  falciform  process 
should  also  be  recognized,  and  likewise  the  internal  saphenous  vein, 
where  it  joins  the  femoral.  The  crural  ring  is  obliterated  by  sutur- 
ing the  lower  edge,  of  Poupart's  ligament  to  the  fascia  which  covers 
the  pectineus  muscle;  i.e.,  to  that  part  of  it  which  covers  the  upper 
part  of  the  pectineus — the  pubic  ligament  of  Cooper.  The  stitches  are 
of  kangaroo  tendon,  and  should  be  introduced  with  a  short,  full-curved 
needle.  The  first  suture  catches  Poupart's  ligament  Just  external  to 
its  attachment  to  the  pubic  spine,  and  should  take  a  good  bite.  After 
the  needle  is  drawn  through,  Poupart's  ligament  is  pulled  upward  and 
backward  with  a  blunt  hook  in  order  to  permit  the  needle  to  catch 
the  pectineal  fascia  as  high  up  under  Poupart's  ligament  as  pos- 
sible; i.e.,  near  the  ilio-pectineal  line,  from  which  the  pectineus  mus- 
cle arises.  Half  a  centimeter  external  to  this  suture  a  second  suture 
is  introduced  in  a  similar  manner,  and  then,  at  a  distance  of  another 
half-centimeter,  a  third  suture.  These  three  sutures  suffice  to  close 
the  opening.  The  third  and  last  suture  is  located  about  1  cm.  to  the 
inner  side  of  the  femoral  vein.  Two  sutures  will  suffice  in  many 
cases.  When  these  sutures  are  tied,  the  lower  edge  of  Poupart's  liga- 
ment and  the  pectineal  fascia  (the  thickened  portion,  high  up  near 
the  origin  of  the  pectineus  muscle  from  the  ilio-pectineal  line)  are 
approximated,  and  the  crural  ring  is  thus  obliterated.  The  opening 
in  the  skin  is  closed  in  the  usual  way.     No  drainage  is  required. 

For  Undescended  Testicle  (Sevan's  Operation) . — The  undescended 
testicle  may  be  found  within  the  abdomen  at  the  internal  ring;  in 
the  inguinal  canal ;  or  external  to  the  inguinal  canal,  underneath  the 
skin.  In  connection  with  this  condition  there  is  almost  always  asso- 
ciated a  patent  vaginal  process  and  therefore  a  condition  of  congenital 
hernia  either  actual  or  latent.  Bevan  advises  that  the  time  to  operate 
is  between  the  ages  of  six  and  twelve  years. 

An  incision  three  inches  long  is  made  from  a  point  half  an  inch 
above  the  middle  of  Poupart's  ligament  to  the  base  of  the  scrotum. 
The  incision  divides  the  integument  and  the  aponeurosis  of  the  ex- 
ternal oblique.  The  edges  of  the  aponeurosis  are  seized  with  artery 
forceps  and  well  retracted,  thus  exposing  the  cremasteric  fascia,  which 
fills  m  the  space  between  the  lower  edge  of  the  internal  oblique  muscle 
(conjoined  tendon)  and  Poupart's  ligament  (see  Pig.  284).  This 
layer  of  fascia  is  incised  together  with  the  underlying  fascia  transver- 
salis,  and  there  is  then  exposed  to  view  the  peritoneal  pouch  or  sac 
within  which  the  testis  is  situated.    When  this  peritoneal  pouch  or  sac 


OPERATIONS  FOR  HERNIA. 


G31 


Fig.  283.— Operation  for  Femoral  Hernia.  FV,  femoral  vein.  Poupart's  liga- 
ment has  been  sutured  to  the  upper  part  of  the  fascia  that  covers  the  pectineus 
muscle — to  the  pubic  ligament  of  Cooper. 


(532  HERNIA,  ETC. 

is  incised  the  testicle  is  exposed  and  the  operator  finds  himself  within 
the  vaginal  process  (tunica  vaginalis),  which  is  found,  as  a  rule,  to 
communicate  direct  with  the  peritoneal  cavity  (see  Pig.  385). 

The  vaginal  process  of  peritoneum  (the  peritoneal  pouch  con- 
taining the  testicle)  is  now  divided  just  above  the  testicle  and  the 
upper  portion  of  it  peeled  upward  away  from  the  structures  that  go 
to  make  up  the  spermatic  cord  and  which  lie  beneath  it;  it  is  then 
transfixed  Avith  the  needle  and  tied  high  up  with  a  catgut  ligature. 
This  portion  of  the  sac  should  be  tied  upon  the  point  of  the  finger 
placed  within  it,  just  as  in  tying  ofi"  an  ordinary  hernia  sac  so  as  not 
to  include  a  process  of  gut  or  omentum  which  might  have  entered  it. 
A  purse-string  suture  is  applied  around  the  edge  of  the  remaining, 
lower,  portion  of  the  vaginal  process,  the  portion  corresponding  to  the 
testis,  drawn  tight  and  tied ;  the  testis  is  thus  inclosed  in  that  portion 
of  the  vaginal  process  which  corresponds  to  the  normal  tunica  vaginalis 
(see  Fig  286). 

The  testicle  is  now  lifted  out  of  its  bed  and  traction  made  upon 
the  cord  in  order  to  lengthen  it  as  much  as  possible.  Tense,  short 
bands  of  connective  tissue  that  bind  the  cord  and  prevent  its  being 
pulled  down  should  be  torn  across  with  thumb  forceps.  The  cord  is 
thus  stripped  of  all  the  surrounding  fascia  and  connective  tissue, 
leaving  nothing  but  the  vessels  of  the  cord  and  the  vas  deferens.  This 
part  of  the  operation  should  be  done  with  care  and  deliberation. 

The  spermatic  vessels  and  vas  deferens,  which  are  situated  behind 
the  posterior  layer  of  the  peritoneum,  within  the  abdominal  cavity, 
should  be  separated  by  careful  blunt  dissection  with  the  finger  within 
the  abdomen.  The  spermatic  vessels  take  a  direction  upward  and 
inward  and  the  vas  downward  and  inward,  and  this  divergence  can  be 
distinctly  appreciated.  The  cord  should  be  sufiiciently  lengthened  by 
these  manipulations  as  to  permit  of  the  testicle  being  drawn  down 
upon  the  thigh,  three  or  four  inches  below  Poupart's  ligament  (see 
Fig.  287). 

A  larger  pocket  is  now  torn  in  the  scrotum  with  the  finger  and 
into  this,  enclosed  in  its  newly  made  tunica  vaginalis,  the  testicle  is 
dropped,  and  here  it  should  remain  without  undue  tension  on  the 
cord.  A  purse-string  suture  is  applied  to  the  neck  of  the  pouch  in 
which  the  testicle  has  been  placed  so  as  to  hold  it  there;  this  suture, 
which  is  of  chromicized  catgut,  includes  the  superficial  fascia,  and  both 
edges  of  the  split  aponeurosis  of  the  external  oblique,  and  when  tied 
retains  the  testis  securely  in  its  new  scrotal  pocket. 


OPERATIONS  FOR  HERNIA. 


G33 


Fig.  284. — For  Undescended  Testis.     Aponeurosis  of  external  oblique  has  been 
split  and  reflected,  exposing  the  cremasteric  fascia. 


frr'^^fli'"^ 


Fig.  285. — For  Undescended  Testis.     Vaginal  process  incised  and  testicle 

exposed. 


634  HERNIA,  ETC. 

The  incision  is  closed  by  suturing  the  conjoined  tendon  to  Pou- 
part's  ligament,  over  the  cord,  thus  burying  the  cord  beneath  them, 
with  a'  sufficient  number  of  interrupted  sutures  of  kangaroo  tendon. 
The  edges  of  the  aponeurosis  of  the  external  oblique  are  then  approxi- 
mated with  a  continuous  suture  of  catgut  and  the  skin  incision  finally 
closed. 

In  some  few  cases  where  the  testis  is  situated  within  the  abdomen 
it  may  be  necessary  to  sever  the  spermatic  vessels  before  the  testis 
can  be  brought  down.  These  vessels  run  an  almost  straight  course 
from  and  to  the  aorta  and  vena  cava,  etc.,  and  on  account  of  their 
relative  shortness  they  may  fix  the  testis  so  that  it  cannot  be  pulled 
down  sufficiently.  The  vessels  should  be  ligated  doubly  and  divided 
between  the  ligatures.  The  testis  may  then  be  more  readily  drawn 
down  toward  the  scrotum.  The  division  of  the  spermatic  vessels  does 
not  interfere  seriously  with  the  nutrition  of  the  testis,  because  suffi- 
cient blood-supply  is  still  provided  through  the  artery  of  the  vas 
deferens,  which  anastomoses  freely  with  the  terminal  branches  of  the 
spermatic  that  are  destined  for  the  supply  of  the  testis.  Special  care 
must  be  exercised  not  to  injure  the  artery  and  veins  of  the  vas  deferens 
nor  to  include  them  in  the  ligatures  with  which  the  spermatic  vessels 
are  secured,  so  that  the  testis  will  not  be  deprived  of  its  entire  blood- 
supply  (see  "Spermatic  Cord"  and  "Varicocele"). 

THE  SPERMATIC  CORD,  SCROTUM,  ETC. 

The  Spermatic  Cord. — The  spermatic  cord  descends  through  the 
inguinal  canal,  emerging  at  the  external  inguinal  ring.  As  it  emerges 
from  the  external  ring  it  lies  just  beneath  the  integument  in  the  sub- 
cutaneous fat,  and  descends  into  the  scrotum,  where  it  is  joined  to 
the  posterior  border  of  the  testis.  It  is  about  as  thick  around  as  the 
little  finger,  and  is  made  up  of  a  bundle  of  structures :  the  vas  deferens, 
the  artery  of  the  vas  deferens,  and  the  cremasteric  artery,  their  corre- 
sponding veins,  the  spermatic  artery,  and  a  tortuous  venous  plexus, 
the  pampiniform.  The  vas  deferens,  the  efferent  duct  of  the  testis, 
occupies  the  posterior  part  of  the  cord.  The  vas  deferens  is  about 
as  big  around  as  a  goose-quill,  has  a  firm  feel,  and  may  be  readily 
recognized  as  it  is  rolled  between  the  fingers.  The  artery  of  the  vas 
deferens  ramifies  upon  the  vas  deferens,  supplies  it,  and  anastomoses 
below  with  the  spermatic  artery.  The  cremasteric  artery  is  distributed 
to  the  constituents  of  the  cord,  and  supples  its  sheath.    The  spermatic 


SPERMATIC  CORD,  SCROTUM,  ETC. 


635 


Fig.  286.— For  Undescended  Testis.  Purse-string  suture  applied  around 
the  edge  of  that  portion  of  the  vaginal  process  which  corresponds  to  the 
tunica  vaginalis. 


Fig.  287.— For  Undescended  Testis.  Upper  portion  of  vaginal  process  tied 
oft.  Lower  portion  encloses  testicles.  Testicle  has  been  freed  and  drawn  down 
preparatory  to  placing  it  in  scrotum. 


636  HERNIA,  ETC. 

artery  is  given  off  from  the  aorta;  it  supplies  the  testis  and  has  a 
strong  current  of  blood.  The  pampiniform  plexus  is  a  tortuous,  in- 
tercommunicating plexus  of  venous  channels  that  accompanies  the 
other  elements  of  the  cord.  Through  this  plexus  the  blood  is  returned 
from  the  testis.  The  vessels  of  the  pampiniform  jolexus  join  together 
above  to  form  the  spermatic  vein.  This  vein  upon  the  right  side 
enters  the  vena  cava  directly;  upon  the  left  side  it  empties  into  the 
renal  vein,  so  that  the  venous  return  on  the  left  side  is  less  direct 
than  upon  the  right  side.  Varicocele  is  usually  found  upon  the  left 
side. 

As  these  structures  traverse  the  inguinal  canal  they  are  all  con- 
tained within  the  infundibular  process,  which  serves  to  bind  them 
together  into  a  single  bundle  and  which  forms  the  real  fibrous  sheath 
of  the  cord,  the  fascia  propria.  Descending  upon  the  cord  is  a  series 
of  looped,  muscular  fibers,  each  joined  to  the  other  by  an  intervening 
thin  fascia.  These  are  the  cremaster  muscle  and  fascia.  These  fibers, 
that  form  the  cremaster  muscle,  are  derived  from  the  lower  border  of 
the  internal  oblique. 

As  the  cord  emerges  from  the  external  inguinal  ring,  the  deep 
layer  of  the  superficial  fascia  (spermatic  fascia),  which  is  attached  to 
the  pillars  or  margins  of  the  ring,  is  continued  down  upon  the  cord, 
inclosing  it  and  forming  one  of  its  investments. 

The  Scrotum. — The  scrotum  is  a  tegumentary  pouch  which  is 
made  up  of  two  compartments,  one  on  each  side,  separated  by  a  median 
septum.  It  consists  of  several  layers  from  without  inward.  The 
skin  is  redundant,  corrugated,  and  wrinkled.  Beneath  the  skin 
is  the  dartos.  The  dartos  is  a  loose,  reddish,  contractile  layer, 
which  is  found  immediately  beneath  the  skin.  It  contains  some  mus- 
cular fibers,  and  is  continuous  behind  with  the  two  layers  of  the  super- 
ficial perineal  fascia,  and  laterally  with  the  same  layers  in  the  groin. 
It  sends  a  septum  into  the  scrotum,  which  divides  it  into  its  two 
halves.  Beneath  the  dartos  is  the  cremaster  muscle  and  fascia,  and 
beneath  this  the  infundibular  fascia,  and,  finallj^,  most  internal,  the 
parietal  layer  of  the  tunica  vaginalis. 

The  Testes. — The  testes  are  situated  in  the  scrotum,  each  sus- 
pended by  its  spermatic  cord.  They  are  partially  invested  by  a  closed, 
serous  sac,  the  tunica  vaginalis.  This  is  the  unobliterated  part  of  the 
vaginal  process  of  the  peritoneum,  the  peritoneal  pouch  that  accom- 
panies the  testis  in  its  descent  from  the  abdomen  into  the  infundibular 
process,  the  scrotum,  before  birth. 


CT.  cavity  of  the  tunica 
vaginalis  testis. 

CT,  cremaster  artery  and 
artery  of  the  vas  deferens 
aud  their  corresponding 
veins,  all  in  close  proxim- 
ity to  the  vas  deferens. 

IK,  internal  inguinal  ring— 
the  mouth  of  the  original 
infundibular  process — 
through  which  the  struct- 
ures that  constitute  the 
cord  escape  (the  infundib- 
ular process  becomes  con- 
tracted around  the  ele- 
ments of  the  cord  and 
forms  th£ir  proper  sheath 
— the  fascia  propria  [red 
linel). 

/',  peritoneum  that  lines  the 
interior  of  the  abdomen. 

S,   symphysis  pubis. 

SAV,  spermatic  artery  and 
veins  (below,  along  the 
course  of  the  cord,  the 
spermatic  veins  consist  of 
a  plexus  of  intercom- 
municating branches — the 
pampiniform  plexus). 

TF,   transversalis  fascia. 

VD,  vas  deferens. 

VP,  remains  of  the  oblit- 
erated vaginal  process  of 
peritoneum  that  accom- 
panies the  testis  in  its 
descent  into  the  scrotum 
(the  arrow  indicates  the 
site  of  the  former  opening 
or  mouth  of  this  process). 


Fig.  288.— Spermatic  Cord. 


Al',  spermatic  artery  and 
pampiniform  plexus. 

FP,  fascia  propria  (sheath 
of  the  cord  and  original 
infundibular  process). 

YD,  vas  deferens  sur- 
rounded closely  by  the 
cremaster  artery  and 
artery  of  the  vas  deferens 
and  their  corresponding 
veins. 

TP,  remains  of  the  obliter- 
ated vaginal  process. 


Fig.  289.— Cross  Section   of   Spermat'c  Cord. 


638  HERNIA,  ETC. 

If  we  cut  through  the  anterior  wall  of  the  scrotum,  through 
these  various  layers,  we  enter  the  cavity  of  the  tunica  vaginalis,  which 
contains  normally  a  small  quantity  of  serous  fluid.  The  testis  pre- 
sents into  this  cavity,  being  partially  invested  by  the  visceral  layer 
of  the  tunica .  vaginalis.  The  posterior  border  of  the  testis  is  not 
covered  by  the  tunica  vaginalis,  and  is  excluded  from  the  cavity  of 
the  tunica  vaginalis. 

Along  the  posterior  border  of  the  testis  is  the  epididymis.  It 
surmounts  the  testis  above  like  a  cap.  It  has  a  body,  an  upper,  larger 
portion,  the  globus  major;  and  a  lower,  smaller  portion,  the  globus 
minor.  The  vas  deferens  is  the  continuation  of  the  epididymis.  It 
commences  at  the  lower  end  of  the  globus  minor,  and,  passing  upward 
along  the  posterior,  inner  border  of  the  testis,  is  found  in  the  pos- 
terior part  of  the  spermatic  cord,  passing  through  the  "internal  ring'^ 
into  the  abdomen.  Within  the  abdomen  it  dips  down  into  the  pelvis, 
to  terminate  between  the  base  of  the  bladder  and  the  rectum,  where 
it  joins  with  the  duct  of  the  seminal  vesicle  of  the  corresponding  side 
to  form  the  ejaculatory  duct. 

The  Ejaculatory  Ducts. — -The  ejaculatory  ducts  are  two  in  num- 
ber, one  on  each  side.  They  are  about  three-fourths  inch  long,  pass 
forward  through  the  prostate  glard,  one  on  either  side  of  the  middle 
line,  between  the  middle  and  lateral  lobes  of  the  prostate,  and  open 
upon  the  floor  of  the  prostatic  urethra. 

OPERATIONS  UPON  THE  SPERMATIC  CORD,  SCROTUM,  ETC. 

For  Varicocele.  Open  Operation. — An  incision  is  made,  about 
one  and  one-half  inches  long,  into  the  upper  part,  of  the  front  of  the 
scrotum,  commencing  just  below  the  spine  of  the  pubes,  and  passing 
through  the  skin  into  the  subcutaneous  fatty  layer.  This  incision 
can  be  made  by  pinching  up  the  skin  and  transfixing  it  with  a  sharp- 
pointed  knife  or  by  cutting  it  with  the  scissors.  The  cord  is  then 
hooked  up,  upon  the  finger,  out  of  the  loose,  fatty  layer  in  which  it 
lies,  and  with  one  or  two  strokes  of  the  knife  its  sheath  (the  spermatic 
fascia  and  the  fascia  propria)  is  opened.  The  vas  deferens  is  sought 
and  recognized,  and  together  with  the  imniediately  adjacent  veins  is 
separated  from  the  other  parts  of  the  cord.  This  is  done  with  the 
fingers,  holding  the  vas  deferens  and  the  several  adjacent  vessels, 
artery  and  veins  of  the  vas,  which  are  to  be  allowed  to  remain  securely 
between  the  finger  and  thumb  of  the  left  hand,  while  the  work  of 


OPERATIONS  UPON  THE  SPERMATIC  CORD,  SCROTUM,  ETC.  (,39 


Fig.  290.— Exposure  of  Spermatic  Cord.  The  spermatic  cord  has  been 
hooked  up  out  of  the  incision  upon  the  finger,  and  its  sheath  incised  prepara- 
tory to  separating  the  vas  deferens  and  adjoining  vessels  from  the  other 
structures  of  the  cord. 


G40 


HERNIA,  ETC. 


separating  the  other  structures  of  the  cord,  veins  of  the  pampiniform 
plexus  and  the  spermatic  artery,  from  the  vas  deferens,  may  he  accoiti- 
plished  with  the  fingers  of  the  right  hand  (see  Fig.  393). 

After  the  vas  deferens,  together  with  the  several  immediately 
adjacent  veins,  has  been  isolated  for  a  distance  varying  from  one  to 
two  inches,  depending  upon  the  laxness  of  the  scrotum  and  the  length 
of  the  cord,  etc.,  a  double  catgut  ligature  is  passed  with  an  arter}^ 
forceps  and  then  cut  so  that  we  have  two  ligatures.  These  ligatures, 
which  surround  all  those  structures  of  the  cord  that  have  been  sepa- 


Fig.  291.— Varicocele.  The  vas  deferens  and  adjoining  vessels  (A)  have  been 
separated  from  the  other  structures  of  the  cord — from  the  spermatic  artery  and 
pampiniform  plexus  (B).  Ligatures  have  been  tied  about  B  above  and  below 
preparatory  to  excising  the  intervening  portion. 

rated  from  the  vas  deferens,  etc.,  are  tied,  one  above  and  the  other 
below.  The  portion  intervening  is  excised  with  the  scissors,  not  too 
close  to  the  ligatures,  and  the  ends  of  the  ligatures,  which  have  been 
purposely  left  long,  are  then  tied  together,  in  this  way  bringing  the 
ends  of  both  stumps  into  apposition.  The  ends  of  these  two  portions 
may  be  still  further  secured  by  one  or  two  catgut  sutures,  which 
should  take  a  good  Inte  through  the  whole  thickness  of  each  stump. 

The  portion  of  the  cord  which  is  stripped  away  from  the  vas 
deferens,  and  which  is  ligated  and  excised,  is  composed  of  all  the 
veins  of  the  pampiniform  plexus  and  the  spermatic  artery.  When 
the  ^as  is  isolated,  the  artery  of  the  vas  deferens,  which  anastomoses 


OPERATIONS  UPON  THE  SPERMATIC  CORD,  SCROTUM,  ETC.    641 


Fig.  292. — ^Varicocele.  Cord  separated  into  two  segments.  Finger  and 
thumb  of  left  hand  grasp  vas  and  adjacent  vessels,  artery  and  veins,  of  vas 
deferens.  Finger  and  thumb  of  right  hand  grasp  spermatic  artery  and  veins  of 
pampiniform  plexus. 


642  HERNIA,  ETC. 

below  with  the  spermatic  artery,  and  the  cremasteric  artery,  together 
with  their  corresponding  veins,  go  with  it;  these  vessels  are  there- 
fore not  interfered  with,  and  they  are  sufficient  to  provide  for  the 
nutrition  of  the  testis  after  the  pampiniform  plexus  and  the  sper- 
matic artery  have  been  ligated. 

For  the  ligatures,  plain  catgTit,  not  too  thick  (Xo.  1  or  2),  may 
be  used,  and  special  care  should  be  taken  to  apply  the  upper  ligature 
securely  that  it  may  not  slip,  as  this  would  result  in  a  very  free  hem- 
orrhage from  the  end  of  the  spermatic  arter}^ 

In  this  operation  one  not  only  ties  off  the  veins  of  the  pam- 
piniform plexus,  but  also  shortens  the  cord,  and  thus  draws  the  testis 
up,  a  result  which  is  much  to  be  desired.  Before  closing  the  incision 
in  the  skin  all  bleeding  points  should  be  clamped  and  ligated  or 
twisted,  and  the  wound  should  be  dry.  The  edges  of  the  incision 
in  the  skin  are  brought  together  with  a  continuous  stitch  of  catgut, 
which  may  be  intracuticular. 

For  Hydrocele. — A  condition  in  which  the  tunica  vaginalis  is 
distended  with  serous  fluid.  The  testis  is  usually  found  in  the  lower, 
back  part  of  the  sac,  the  fluid  being  collected  above  and  in  front 
of  it. 

ru]s'CTURE  AND  INJECTION". — This  is  Suitable  for  simple  cases, 
and  for  those  where  tapping  has  not  been  previously  resorted  to. 
The  scrotum  is  grasped  in  the  left  hand,  in  order  to  make  it  tense 
and  to  steady  it.  A  fine  needle,  attached  to  a  hypodermic  s}T*inge,  is 
introduced  through  the  anterior  wall  of  the  scrotum,  and  a  small 
quantity  of  the  fluid  drawn  off,  both  for  the  purpose  of  confirming 
the  diagnosis  and  to  demonstrate  the  fact  that  the  needle  is  in  the 
cavity  of  the  tunica  vaginalis.  The  hj'podermic  needle  is  left  in  situ, 
its  end  free  in  the  caAdty  of  the  tunica  vaginalis.  A  fairly  large 
trochar  is  then  thrust  through  the  bottom  of  the  scrotum  rather 
toward  the  front,  and  in  an  upward  direction  into  the  cavity  of  the 
tunica  vaginalis.  In  doing  this  one  should  remember  that  the  testis 
occupies  the  lower  back  part  of  the  sac.  With  the  trochar  in  the  cavity 
of  the  tunica  vaginalis  one  should  be  able  with  it  to  touch  the  hypo- 
dermic needle  previously  introduced  into  the  sac  above.  The  sac  is 
allowed  to  empty  itself  through  the  cannula,  and  this  is  then  with- 
drawn. 

The  barrel  of  the  hypodermic  S3^ringe  is  now  filled  with  the 
fluid  to  be  injected.  Twenty  minims  of  a  95-per-cent.  carbolic-acid 
solution  may  be  used,   with   satisfactory  results,   for   this  purpose. 


OPERATIONS  UPON  THE  SPER:\L\TIC  CORD,  SCROTUM,  ETC.     643 

This  is  thrown  into  the  cavity  of  the  tunica  vaginalis  through  the 
hypodermic  needle,  and  then  this  needle  is  also  withdrawn.  The 
fluid  that  has  been  thus  introduced  into  the  cavity  of  the  tunica 
vaginalis  is  distributed  over  the  whole  cavity  by  manipulating  the 
scrotum.  The  punctures  made  by  the  instruments  are  covered  over 
with  a  thin  coat  of  collodion,  and  a  very  thin  film  of  absorbent 
cotton. 


Fig.  293.— Hydrocele,  Tapping.  CTV,  cavity  of  the  tunica  vaginalis  testis; 
T,  testis;  V,  vas  deferens.  Hypodermic  needle  introduced  into  the  upper  part 
of  the  sac;   trochar  cannula  into  the  lower  part. 


This  operation  is  usually  followed  by  some  effusion  into  the  sac, 
and  with  but  little  or  no  pain.  After  a  few  days'  rest  in  bed  with 
the  scrotum  supported,  these  sjmiptoms  subside.  The  operatoin  is 
not  painful,  but  the  part  where  the  trochar  is  to  be  introduced  mav 
be  anesthetized  with  ethyl  chloride  if  desired. 

Open  Operation  (Volkimanx). — ^This  operation  is  suitable  for 
those  cases  that  have  already  been  tapped  many  times  or  where  the 
operation  previously  described  has  been  tried  and  has  failed. 


644  HERNIA,  ETC. 

The  scrotum  is  grasped  by  an  assistant  in  order  to  make  it  tense 
and  to  steady  it.  An  incision  is  made  through  the  anterior  wall  of 
the  scrotum^  opening  into  the  cavity  of  the  tunica  vaginalis.  The 
length  of  the  incision  depends  upon  the  size  of  the  tumor,  but  is 
usually  two  or  three  inches.  When  the  tunica  vaginalis  has  been 
opened,  and  while  the  fluid  is  escaping,  the  edge  of  the  parietal  layer 
of  the  tunica  vaginalis^ — i.e.,  the  inner  lining  of  the  scrotal  sac — is 
seized  on  either  side  with  an  artery^  forceps,  and  with  the  finger  this 
is  torn  away  from  its  attachment  to  the  inner  aspect  of  the  scrotum, 
and  excised  in  part  with  the  scissors.  If  the  tumor  has  been  very 
large,  it  will  be  necessary  to  excise  more  of  the  tunica  vaginalis  than 
if  the  tumor  is  smaller.  The  tunica  vaginalis  may  be  much  thick- 
ened. In  trimming  away  this  redundant  portion  of  the  tunica  vag- 
inalis one  must  take  care  to  leave  enough  to  conveniently  cover  the 
testis  and  also  avoid  cutting  into  the  epididymis.  It  is  rather  better 
to  excise  too  little  than  too  much  of  the  tunica  vaginalis.  After  this 
part  of  the  operation  has  been  done  the  edge  of  that  portion  of  the 
tunica  vaginalis  which  remains  is  fixed  to  the  corresponding  edge 
of  the  skin  incision  all  around  with  a  continuous  or  with  several 
interrupted  fine  catgut  sutures.  Then,  with  a  wad  of  cotton  on  a 
stick,  the  whole  interior  of  what  remains  of  the  tunica  vaginalis,  in- 
cluding that  covering  the  testis,  is  swabbed  out  with  95-per-cent. 
carbolic  acid.  The  cavity  is  then  loosely  packed  with  sterile  gauze. 
The  strips  should  reach  well  down  into  the  deepest  recesses  of  the 
cavity,  but  the  packing  should  not  be  tight.  A  loose  dressing  is 
applied,  which  may  be  held  in  place  by  a  T-bandage.  The  packing 
should  be  removed  at  the  end  of  forty-eight  hours,  simply  retaining 
a  strip  in  the  opening  in  the  skin,  and  the  parts  allowed  to  granulate. 
If  too  much  of  the  tunica  has  been  removed,  there  will  be  too  much 
inversion  of  the  skin,  and  this  will  delay  the  healing  process. 

Excision  of  the  Tunica  (von  Bergmann). — After  the  tunica 
vaginalis  sac  has  been  opened  and  its  contents  evacuated,  the  parietal 
la5^er  of  the  tunica  vaginalis  is  seized  and  stripped  away  from  its 
attachment  bluntly  with  the  fingers  as  far  back  as  the  posterior  bor- 
der of  the  testis,  or  rather  epididymis,  and  then  excised  in  its  en- 
tirety with  the  scissors.  After  all  bleeding  has  been  controlled  with 
forceps  and  ligatures,  the  wound  in  the  skin  is  closed  with  sutures, 
without  any  drainage  whatever.  As  a  rule,  the  skin  incision  heals 
by  first  intention,  and  the  patient  is  able  to  be  around  in  about  twelve 
days. 


OPERATIONS  UPON  THE  SPERMATIC  CORD,  SCROTUM,  ETC.    645 


Fig.  294.— Volkmann  Operation  for  Hydrocele.     Edge  of  tunica  vaginalis  sutured 
to  the  edges  of  the  skin  incision. 


646  HERNIA,  ETC. 

This  method  is  very  satisfactory,  and  is  especially  applicable  to 
those  cases  where  the  tunica  vaginalis  is  excessively  redundant  after 
the  evacuation  of  a  large  hydrocele,  or  when  the  tunica  is  markedly 
thickened. 

Eetroveesion  of  the  Tunica  Vaghstalis. — This  method  has 
been  variously  ascribed  to  Jaboulay,  Doyen,  Garampozzi,  and  Win- 
kelniann.  An  incision  is  made  in  the  front  of  the  scrotum,  usually 
aboul,  two  inches  in  length,  into  the  cavity  of  the  tunica.    Through 


Fig.  295. — Hydrocele.     Retroversion  of  the   tunica  vaginalis.     The   tunica  has 
been  turned  back  beyond  the  epididymis  and  fixed  there  by  sutures. 


this   opening  the   fluid   contents   of  the   distended  tunica  vaginalis 
escape,  and  the  testis  is  then  drawn  forward  out  of  the  scrotum. 

As  the  testis  is  drawn  forward  out  of  the  scrotum,  the  vaginal 
layer  of  the  tunica  is  reflected  backward, — turned  inside  out,  as  it 
were, — so  that  the  opening  in  the  parietal  layer  of  the  tunica, 
through  which  the  testis  has  been  drawn,  gets  to  lie  behind  the  testis, 
encircling  the  cord  and  covering  over  the  epididymis,  and  in  this 
position  it  is  fixed  by  joining  its  edges  together  with  several  catgut 
sutures  so  that  it  may  not  again  slip  forward  over  the  testis.  The 
edges  of  the  incision  in  the  scrotum  are  now  sufficiently  detached  to 
allow  the  inteo-ument  of  the  scrotum  to  be  drawn  forward  and  cover 


OPERATIONS  UPON  THE  SPERMATIC  CORD,  SCROTUM,  ETC.     647 


Fig.  296. — Castration.  Cord  has  beeu  divided.  The  end  of  the  lower  portion 
grasped  with  an  artery  forceps.  A  ligature  has  been  tied  around  the  end  of 
the  upper  stump.  It  will  be  noticed  that  the  vas  deferens  is  not  included  in  the 
ligature. 


648  HERNIA,  ETC. 

over  the  testis  and  reflected  tunica  vaginalis,  and  the}^  are  thus  united 
to  each  other  without  drainage,  in  this  way  completing  the  operation. 

The  result  of  this  operation  is  that  the  free  secreting  surface  of 
the  tunica  vaginalis  which  has  been  turned  inside  out  is  brought  into 
contact  with  the  raw  internal  wound  surface  of  the  scrotum,  to  which 
it  becomes  united,  effecting  the  cure. 

If  the  tunica  vaginalis  is  very  redundant  after  evacuating  a 
large  hydrocele,  a  part  of  the  tunica  may  be  excised  with  the  scissors, 
leaving  just  enough  to  complete  the  operation  as  described  above;  but 
for  those  verj^  large  hydroceles,  and  those  with  a  markedly  thickened 
tunica,  the  von  Bergmann  is  probably  the  more  satisfactory  opera- 
tion. 

Castration  (Extirpation  of  the  Testis). — An  incision,  about  two 
inches  long,  is  made  upon  the  front  of  the  upper  part  of  the  scrotum 
through  the  skin  and  fat,  commencing  at  a  point  just  below  the  ex- 
ternal ring— the  spine  of  the  pubes.  If  operating  for  malignant  dis- 
ease, and  if  the  skin  is  involved,  the  incision  m&j  be  arranged  so  as 
to  circumscribe  that  part  of  the  skin  which  is  involved.  In  the  upper 
part  of  the  incision  the  cord  is  found,  and  hooked  up,  upon  the  finger, 
and  just  below  the  point  where  it  emerges  from  the  external  ring  its 
sheath  is  incised  with  the  point  of  the  knife.  The  vas  deferens  is  then 
recognized,  and  should  be  separated  from  the  rest  of  the  cord.  A 
catgut  ligature  is  then  passed  about  those  parts  of  the  cord  which 
have  been  separated  from  the  vas  deferens,  and  tied  so  tightly 
that  it  cannot  slip  off.  This  ligature  should  include  all  the  elements 
of  the  cord  except  the  vas  deferens.  The  ends  of  this  ligature  are 
left  long,  to  serve  as  a  tractor;  the  cord,  including  the  vas  deferens, 
is  then  divided  with  the  scissors,  at  least  half  an  inch  below,  distal 
to  the  ligature.  Before  dividing  the  cord  it  is  grasped,  below  the 
point  at  which  it  is  to  be  divided,  with  an  artery  clamp.  The  cord 
having  been  divided,  the  lower  end,  that  which  is  held  in  the  grasp 
of  the  artery  forceps,  together  with  the  testis,  and  including  the  tunica 
vaginalis,  is  enucleated  from  the  scrotum,  usually  without  opening 
into  the  cavity  of  the  tunica  vaginalis,  and  almost  entirely  by  blunt 
dissection.  Where  the  knife  or  scissors  is  used  to  assist  in  this  enu- 
cleation one  should  take  care  not  to  cut  through  the  septum  into 
the  oiher  half  of  the  scrotum,  and  one  should  also  avoid  button-holing 
the  skin. 

After  the  testis  has  been  eniTcleated  we  return  to  the  stump  of 
the  cord.     Thi?,  may  be  brought  into  view  by  drawing  upon  the  liga- 


OPERATIONS  UPON  THE  SPERMATIC  CORD,  SCROTUM,  ETC.     64^ 

ture,  which  was  left  long  to  serve  as  a  tractor,  and  if  there  is  no  bleed- 
ing this  ligature  may  be  cut  short  and  the  stump  of  the  cord  allowed 
to  retract  up  into  the  inguinal  canal.  Should  there  be  any  bleeding 
points,  these  may  be  clamped  and  ligated.  One  should  avoid  includ- 
ing the  stump  of  the  vas  deferens  in  the  ligature,  as  it  may  result  in 
disagreeable  symptoms;  e.g.,  colicky  pain,  etc. 

The  wound  is  large,  and  may  be  closed  with  catgut  sutures;  in 
most  cases,  however,  it  is  well  to  place  a  drain  in  the  lower  end  of  T-he 
wound.  If  operating  for  tuberculosis,  the  cord  should  be  divided  as 
high  up  as  one  can  reach. 


PART  VIII. 

THE  URINARY  SYSTEM. 

The  Surgical  Anatomy  of  the  Kidney. — One  kidney  may  be  absent 

in  apparently  normal  subjects,  the  left  more  frequently  than  the  right. 
This  is  said  to  occur  once  in  about  two  thousand  four  hundred  sub- 
jects. When  one  kidney  is  absent  that  which  is  present  is  usually 
larger  and  assumes  the  function  of  both  kidneys. 

There  may  be  two  kidneys  present,  joined  together  below  or 
above,  horseshoe  kidney,  or  both  above  and  below,  either  with  con- 
nective tissue  or  kidne)''  tissue.  This  condition  is  met  with  about 
once  in  one  thousand  subjects. 

The  position  of  the  kidneys  is  not  fixed.  They  move  normally 
within  certain  limits  with  respiration,  descending  with  each  inspira- 
tion. The  kidneys  are  situated  in  the  upper  back  part  of  the 
abdomen,  one  on  each  side  of  the  vertebral  column,  occupying  the 
space  from  the  twelfth  dorsal  to  the  third  lumbar  vertebra.  The 
right  kidney  is  located  one  inch  lower  than  the  left  on  account  of 
the  presence  of  the  thick  border  of  the  liver  on  the  right  side.  The 
upper  part  of  the  left  kidney  lies  under  the  eleventh  and  twelfth 
ribs;  the  upper  part  of  the  right  kidney  under  the  twelfth  rib.  In 
the  female  both  kidneys  are  situated  somewhat  lower  than  in  the 
male.  The  lower  pole  of  the  kidney  reaches  to  within  one  or  two 
inches  of  the  crest  of  the  ilium.  The  kidneys  are  placed  somewhat 
obliquely  in  the  abdomen  so  that  the  upper  poles  are  rather  closer 
together  than  the  lower  poles.  The  kidneys  are  extraperitoneal  or- 
gans;  they  lie  behind  the  peritoneum. 

The  kidneys  are  provided  with  a  fibrous  capsule,  which  is  usually 
quite  dense  and  closely  adherent  to  the  organ.  The  kidneys  are 
lodged  within  a  bed  of  loose  fat  and  connective  tissue,  out  of  which 
they  may  be  readily  enucleated.  The  anterior  surface  of  the  kidney 
is  directed  forward  and  outward,  and  is  covered  by  the  peritoneum. 
The  colica  dextra  artery  and  vein  pass  outward  across  the  front  of 
the  right  kidney  underneath  the  peritoneum,  and  the  colica  sinistra 
artery  and  vein  across  the  front  of  the  left  kidney  underneath  the 
peritoneum  to  supply  the  ascending  and  descending  portion  of  the 
colon.  The  descending  part  of  the  duodenum  lies  in  front  of  the 
right  kidney,  the  pancreas  in  front  of  the  left  kidney. 
(650) 


SURGICAL  ANATOMY  OF  THE  KIDNEY. 


651 


The  upper  part  of  the  posterior  surface  of  the  kidney  is  separated 
from  the  eleventh  and  twelfth  ribs  by  the  diaphragm  and  pleura ; 
the  lower  part  of  the  posterior  surface  of  the  kidney  rests  upon  the 
quadratus  lumboruni  muscle  which  is  covered  by  the  anterior  layer 
of  the  lumbar  fascia. 

The  inner  border  of  the  kidney  is  concave  and  is  directed  toward 
the  psoas  muscle  and  tlie  vertebral  column.  The  inner  border  of  the 
kidney  really  rests  upon  the  edge  of  the  psoas  muscle  and  the  organ 


C.min. 


Fig.  297.— Right  Kidney  from  Behind.  Posterior  part  of  the  kidney  cut  away 
to  show  the  sinus  and  structures  contained  therein.  A.,  renal  artery;  C.maj., 
calices  majores;  C.min.,  calices  minores;  P.,  pelvis  of  the  kidney;  T.,  renal 
vein. 

is  thus  tilted  somewhat  outward.  This  border  of  the  kidney  presents 
a  long,  slit-like  opening,  the  hiluni.  Through  the  hilum  the  renal 
vessels,  etc.,  pass  into  a  comparatively  large,  narrow  space  between 
the  two  halves  of  the  kidney,  called  the  sinus.  The  sinus  lodges  the 
renal  vessels  and  the  pelvis  of  the  kidney.  Within  the  sinus  the 
pelvis  of  the  kidney  occupies  a  position  posterior  to  the  renal  artery 
and  vein.  The  renal  artery  enters  the  hilum  and  divides,  within  the 
sinus,  into  two  groups  of  bran'ches :  an  anterior  group,  the  larger, 
and  a  posterior  group,  the  smaller.  These  two  sets  of  branches  are 
disposed  within  the  sinus  in  front  of,  and  behind,  the  tubules  that 


653  UEINAEY  SYSTEM. 

join  to  form  the  pelvis  of  the  kidne5^  Each  set  of  branches,  five  or  six 
in  number,  penetrate  the  substance  of  the  kidney  to  supply  the  cor- 
responding anterior  and  posterior  portions  of  the  organ.  The  terminal 
branches  of  the  two  groups  of  branches  into  which  the  renal  artery 
divides  do  not  anastomose  with  each  other;  hence  there  is  a  plane  be- 
tween the  two  separately  vascularized  portions  of  the  kidney  which  may 
be  incised  without  much  hemorrhage.  This  is  called  the  bloodless  zone 
of  Hyrtl.  It  corresponds  to  a  line  drawn  along  the  outer  border  of  the 
kidney,  somewhat  nearer  the  posterior  than  the  anterior  surface,  about 
one-half  inch  nearer  the  posterior  surface.  The  kidney  may  be  split 
through  this  plane  down  into  the  pelvis  with  only  a  minimum  amount 
of  hemorrhage.  The  renal  vein  is  formed  within  the  sinus  of  the 
kidney  by  the  junction  of  a  number  of  branches  corresponding  to 
those  of  the  renal  artery.  The  right  renal  vein  is  shorter  than  the 
left  owing  to  the  position  of  the  vena  cava  upon  the  right  side  of 
the  vertebral  column,  hence  the  right  kidney  presents  a  shorter 
pedicle  than  the  left  kidney  in  the  operation  of  nephrectomy.  At 
the  hilum  the  relation  of  the  structures  from  before  backward  is 
vein,  SLi'tery,  ureter.     The  ureter  is  the  lowest  of  the  three  structures. 

The  outer  border  of  the  kidney .  is  rounded  and  convex  and  is 
related^  the  right,  with  the  ascending  colon,  and  the  left  with  the 
descending  colon.  The  colon  really  lies  a  little  in  front  of  the  kidney, 
as  well  as  to  its  outer  side. 

The  upper  end  of  the  kidney  is  covered  by  the  suprarenal  cap- 
sule, which  sits  upon  it  like  a  cap.  The  upper  end  of  the  right  kidney 
is  in  close  relation  with  the  under  surface  of  the  liver.  The  upper 
end  of  the  left  kidney  lies  close  to  the  spleen.  The  lower  end  of  the 
kidney  reaches  to  within  one  or  two  inches  of  the  crest  of  the  ilium. 

The  kidneys  are  imbedded  in  a  mass  of  loose  fatty  tissue — the 
fatty  capsule.  The  fatty  capsule  is  arranged  in  two  layers  sup- 
ported by  septa  of  fibrous  tissue.  Occasionally  the  kidneys  be- 
come quite  loose,  especially  after  the  loss  of  a  considerable  amount 
of  the  intra-abdominal  adipose  tissue  and  may  then  become  abnor- 
mally movable.  They  can  be  felt  to  descend  with  each  deep  inspira- 
tion, between  the  hands.  One  hand  is  placed  behind,  in  the  lumber 
region,  pressing  upward,  and  the  other  hand  is  placed  in  front, 
pressing  upon  the  abdominal  wall  anteriorly.  At  times  the  kidney 
becomes  so  loose  that  it  leaves  the  lumbar  region  entirely  and  drops 
down  into  the  iliac  fossa  so  that  it  rests  upon  the  brim  of  the  pelvis. 
Under  these  circumstances  the  renal  vessels  may  become  twisted  and 


SURGICAL  ANATOMY  OF  THE  KIDNEY.  G53 

the  ureter  may  become  kinked  so  that  the  flow  of  urine  is  obstructed, 
thus  giving  rise  to  a  condition  of  hydronephrosis — distention  of  the 
pelvis  of  the  kidney— associated  with  symptoms,  pain,  hasmaturia, 
etc.,  that  greatly  resemble  attacks  of  renal  colic. 

The  Pelvis  of  the  Kidney. — The  pelvis  of  the  kidney  is  a 
pyramidal-shaped,  thin-walled,  membranous  sac  into  which  the 
urine  is  discharged  as  it  is  excreted  from  the  kidney.  It  is  con- 
tinuous below  with  the  ureter,  which  conducts  the  urine  from  the 
pelvis  of  the  kidney  to  the  bladder.  The  pelvis  of  the  kidney  is 
contained  almost  wholly  within  the  sinus  of  the  kidney — the  narrow 
space  within  the  kidney  between  the  two,  anterior  and  posterior, 
segments.  It  occupies  a  position,  within  the  sinus,  posterior  to  the 
renal  vessels.  The  pelvis  of  the  kidney  is  formed  by  the  junction 
of  two  or  three  thin-walled  tubes, — the  calyces  majores.  Each 
calyx  major  is  in  turn  made  up  of  several  smaller  tubes, — the 
calyces  minores.  The  calyces  minores  are  ten  or  twelve  in  number. 
Little  cone-shaped  bodies,  the  papillae,  project  into  the  calyces  mi- 
nores— usually  two  or  three  into  a  single  calyx.  The  summit  of  each 
papilla  is  marked  by  a  number  of  minute  openings,  the  foramina 
papillaria,  which  are  the  orifices  of  the  secreting  tubules. 

The  Ureters. — The  ureter  is  a  long,  thick-walled  duct,  about 
eleven  inches  long,  flattened  from  before  backward,  which  leads  from 
the  pelvis  of  the  kidney  to  the  bladder.  It  descends  in  the  back 
part  of  the  abdomen,  behind  the  peritoneum,  and  dips  into  the  pelvic 
cavity  over  the  brim  of  the  pelvis  near  the  corresponding  sacro- 
iliac synchondrosis.  As  it  dips  into  the  pelvis  it  crosses  the  bifurca- 
tion of  the  common  iliac  artery  or  the  external  iliac  artery  just 
after  this  branch  is  given  off  from  the  common  iliac. 

The  abdominal  portion  of  the  ureter  is  about  five  inches  long. 
It  passes  downward  and  slightly  inward,  lying  upon  the  psoas 
muscle,  in  close  company  with  the  spermatic  and  ovarian  vessels  and 
the  genito-crural  nerve.  The  right  ureter  lies  close  to  the  vena  cava. 
The  ureters  are  situated  behind  the  peritoneum,  to  which  they  are 
quite  closely  adherent.  Upon  the  left  side  the  line  of  attachment  of 
the  mesentery  of  the  sigmoid  flexure  (pelvic  colon)  crosses  the  ureter. 
The  inferior  mesenteric  artery  and  vein  are  in  close  relationship 
with  the  left  ureter  as  it  crosses  the  iliac  vessels  to  dip  into  the 
pelvic  cavity. 

The  pelvic  portion  of  the  ureter  is  about  five  inches  long.  In 
the  pelvis  the  ureters  lie  close  to  either  lateral  wall  of  the  pelvic 


654  URINARY  SYSTEM. 

cavity,  immediately  underneath  the  peritoneal  layer  that  lines  the 
cavity.  After  descending  a  short  distance  upon  the  lateral  wall  of 
the  pelvis  they  curve  forward  and  inward  to  reach  the  bladder.  In 
the  male  the  vas  deferens  passes  across  the  ureter  from  behind  for- 
ward and  to  its  inner  side,  just  before  the  latter  (ureter)  reaches  the 
bladder.  As  the  ureters  pierce  the  wall  of  the  bladder,  they  are  about 
two  inches  apart.  They  pierce  the  bladder  just  above  and  anterior  to 
the  upper  extremity  of  the  seminal  vesicles.  In  the  female  the  ureter 
passes  inward  and  forward,  close  to  the  floor  of  the  pelvis  between  the 
layers  of  the  broad  ligament,  to  reach  the  bladder.  In  its  course  it  lies 
about  three-quarters  of  an  inch  to  the  outer  side  of  the  cervix  and  very 
close  to  the  upper  part  of  the  wall  of  the  vagina — ^just  external  to  the 
lateral  fornix  of  the  vagina.  A  stone  in  the  lower  part  of  the  ureter 
in  the  female  may  be  felt  through  the  vaginal  wall  and  may  be 
removed  through  an  incision  in  the  wall  of  the  vagina.  The  ureter 
also  has  an  important  relation  to  the  uterine  artery.  The  uterine 
artery  arises  from  the  anterior  division  of  the  internal  iliac  and 
passes  inward  between  the  layers  of  the  broad  ligament,  to  reach  the 
uterus  at  about  the  junction  of  the  cervix  with  the  body,  where  it 
ascends  upon  the  side  of  the  uterus  to  supply  it.  The  uterine  artery 
in  its  course  to  the  uterus  passes  across  the  front  of  the  ureter  about 
three-quarters  of  an  inch  to  the  outer  side  of  the  cervix. 

The  ureters  penetrate  the  wall  of  the  bladder  very  obliquely — 
traversing  the  muscular  layer  of  the  bladder  for  nearly  three- 
quarters  of  an  inch  before  they  open  upon  the  inner  surface  of  the 
bladder.  The  openings  are  slit-like  and  protected  by  a  little  valve- 
like fold  of  mucous  membrane  so  that  there  is  quite  some  hindrance 
to  the  backward  passage  of  fluid  from  the  bladder  into  the  ureters. 
When  the  bladder  is  distended  the  distance  between  the  orifices  of 
the  ureters  becomes  increased.  They  are  then  about  two  inches  apart. 
The  lumen  of  the  ureter  will  permit  passage  of  a  Fo.  9  French 
bougie.  The  ureter  is  constricted  at  several  points  and  somewhat 
dilated  between  these.  It  is  constricted  about  the  middle  of  the 
abdominal  portion,  about  two  inches  below  the  pelvis,  where  it  has 
a  diameter  of  about  one-seventh  inch,  again  at  the  pelvic  brim,  junc- 
tion of  the  abdominal  and  pelvic  portions,  where  the  diameter  is 
about  one-quarter  inch,  and  again  at  the  lower  end,  just  before  it 
opens  into  the  bladder,  within  one-half  inch  of  the  bladder  orifice, 
where  it  is  narrowest,  the  diameter  being  about  one-tenth  inch.  These 
constrictions  represent  the  favorite  sites  for  lodgment  of  a  calculus. 


OPERATIONS  UPON  THE  KIDNEY. 


655 


Either  ureter  may  be  represented  by  two  tubes,  through  all  or 
part  of  its  course.  In  the  former  case  there  will  be  two  openings 
in  the  bladder  upon  the  corresponding  side.  The  presence  of,  at  least, 
one  ureteral  orifice  on  each  side  of  the  bladder,  from  which  urine  is 
seen  to  escape,  is  quite  positive  evidence  of  the  presence  of  two  kidneys. 

OPERATIONS  UPON  THE  KIDNEY. 

Nephropexy. — Suture  or  fixation  of  a  movable  or  floating  kidney. 
A  movable  kidney  is  one  that  enjoys  a  limited  range  of  motion 


fiTr wy 


Fig.  298. — Incision  for  Exposure  of  the  Kidney.    Patient  lies  prone,  with 
Edebohls'    rubber  cushion   under  the  abdomen. 

in  the  posterior  part  of  the  abdomen,  but  which  does  not  leave  the 
lumbar  region.  A  floating  kidney  is  one  that  enjoys  a  considerable 
range  of  motion  and  is  capable  of  leaving  the  lumbar  region  entirely. 
It  may  be  more  or  less  completely  invested  with  a  peritoneal  coat 
and  provided  with  a  more  or  less  complete  mesonephron.  As  a  result 
of  the  displacement  of  the  kidney  the  renal  vessels  may  become 
twisted  and  the  ureter  acutely  kinked,  the  flow  of  urine  obstructed 
and  a  condition  of  hydronephrosis  with  accompanying  pain,  etc.,  pro- 
duced. The  indication  for  nephropexy  will  depend  upon  the  degree 
of  discomfort,  etc.,  that  the  loose  kidney  causes. 

The  patient  lies  prone  upon  the  table  with  an  Edebohls  rubber 
cushion  under  the  abdomen.     A  sandbag  placed  imder  the  upper  part 


656 


URINARY  SYSTEM. 


of  the  chest  will  materially  relieve  the  embarrassment  of  respiration 
■which  occurs  in  this  position. 

The  incision  corresponds  to  the  outer  border  of  the  erector 
spinas  muscle,  commencing,  above,  at  the  twelfth  rib,  about  two  and 
a  half  inches  from  the  middle  line.  It  passes  downward,  curving 
somewhat  outward,  and  terminates  just  above  the  crest  of  the  ilium. 
This  incision  should  extend  through  the  skin  and  subcutaneous  fat 
down  to  the  surface  of  the  aponeurosis  of  the  latissimus  dorsi  muscle. 
The  incision  is  then  carried  through  the  aponeurosis,  when  the  outer 


Fig.  299.— Lumbar  Incision  for  Exposing  the  Kidney.  E.S.,  erector  spinas; 
I.E.,  ilio-hypogastric  nerve;  L.D.,  edges  of  the  aponeurosis  of  the  latissimus 
dorsi;  Q.L.,  quadratus  lumhorum;  12. D.,  twelfth  dorsal  nerve. 


horder  of  the  erector  spinse  muscle  is  recognized.  This  muscle  is 
drawn  toward  the  middle  line  with  a  blunt  tractor.  The  quadratus 
lumborum,  covered  by  its  proper  layer  of  the  lumbar  fascia,  is, then 
exposed  in  the  bottom  of  the  incision.  The  fascia  that  covers  the 
quadratus  lumborum  is  incised  along  the  edge  of  the  erector  spinse. 
The  quadratus  extends  a  little  beyond  the  edge  of  the  erector  spinse. 
The  outer  edge  of  the  quadratus  is  thus  exposed  and  this  muscle  is 
likewise  drawn  inward,  toward  the  middle  line,  with  the  tractor.  The 
ilio-hypogastric  nerve  appears  at  the  outer  edge  of  the  quadratus  lum- 
horum,  about  the  middle  of  the  incision  and  the  twelfth  dorsal  nerve 


OPERATIONS  UPON  THE  KIDNEY. 


657 


at  the  outer  edge  of  the  muscle  in  the  upper  part  of  the  incision. 
These  nerves  pass  obliquely  downward  and  outward  across  the  front 
of  the  quadratus  lumborum  and  are  usually  readily  recognized  after 
the  edge  of  the  muscle  has  been  exposed.  These  nerves  should  not 
be  cut  but  rather  drawn  to  one  side,  out  of  the  way,  with  the  fingers. 
Later,  in  introducing  sutures,  the  nerves  should  also  be  avoided,  not 
included  in  the  loops  of  the  sutures.  The  several  layers  of  fascia, 
as  they  are  encountered  in  the  incision,  should  be  split  for  the  full 
length  of  the  skin  incision,  upward  to  the  lower  border  of  the  last 


Fig.  300.— Nephropexy.  Kidney  delivered  through  an  incision  in  the  back. 
Proper  fibrous  capsule  reflected  and  two  fixation  sutures  introduced,  one  above 
(.A, A')  and  one  below  (B,B').  These  sutures  pass  through  the  reflected  and 
attached  portions  of  the  capsule  close  to  the  line  of  reflection.  The  two  sutures 
that  secure  the  capsule  upon  the  opposite  side  of  kidney  are  not  seen. 


rib  and  downward  as  far  as  the  crest  of  the  ilium.  There  remains 
now  only  the  deepest  and  last  layer  of  the  lumbar  fascia  to  be  incised. 
This  layer  is  picked  up  with  tooth  forceps  and  incised  with  the  knife 
and  then  split,  upward  toward  the  last  rib  and  downward  toward  the 
crest  of  the  ilium,  with  the  scissors  or  with  the  fingers.  After  this 
last  layer  of  the  lumbar  fascia  has  been  incised  the  fatty  capsule,  in 
which  the  kidney  is  embedded,  is  encountered.  This  is  separated 
from  the  kidney  bluntly  with  the  fingers  and  the  kidney  freed  and 
detached  all  around  so  that  it  may  be  brought  up  out  of  the  incision. 
The  isolation  of  the  kidney  is  accomplished  with  gentleness,  sweeping 

42 


658  URINARY  SYSTEM. 

the  fingers  around  the  kidney,  between  it  and  the  fatty  capsule; 
around  the  free  outer  border,  over  the  upper  and  lower  poles  and 
avoiding  the  inner  border,  the  vessels  at  the  hilum.  Eough  handling 
and  pulling  upon  the  kidney  is  to  be  avoided.  If  the  kidney  is  dis- 
placed, movable,  it  is  easy  to  reach  it  as  it  lies  lower  in  the  abdomen. 
The  right  kidney  is  situated  lower  than  the  left.  When  the  kidney 
has  been  sufficiently  separated  it  can  be  brought  up  into  the  incision 
and  out  upon  the  back  for  the  subsequent  steps  of  the  operation. 
The  prone  position  of  the  patient  and  the  rubber  bag  under  the 
abdomen  make  the  delivery  of  the  kidney  out  of  the  incision  com- 
paratively easy.  While  the  kidney  is  being  isolated  care  must  be 
exercised  not  to  tear  through  the  proper  fibrous  capsule  of  the  kidney, 
since,  if  this  accident  occurs,  one  may  detach  the  capsule  of  the 
kidney  from  the  kidney  substance  proper,  instead  of  isolating  the 
kidney  with  its  proper  capsule  intact  from  the  loose  mass  of  fat  in 
which  it  is  lodged. 

After  the  kidney  has  been  delivered  through  the  incision  the 
proper  fibrous  capsule  is  incised  along  the  entire  length  of  the  outer, 
rounded  border  of  the  kidney  and  peeled  back  for  a  distance  of  about 
one  inch  on  each  side. 

Four  fixation  sutures  of  medium-sized  kangaroo  tendon  are  in- 
troduced in  the  reflected  capsule,  upon  the  sides  of  the  kidney.  These 
sutures  are  placed  two  on  each  side,  one  near  the  upper  pole  of  the 
kidney  and  the  other  near  the  lower  pole.  Each  suture  takes  a  good 
broad  bite  in  the  reflected  portion  of  the  capsule  and  the  attached 
portion  of  the  capsule  immediately  beneath,  and  are  placed  parallel 
with  and  quite  close  to  the  margin  that  corresponds  to  the  line  of 
reflection  of  the  capsule.  After  these  four  fixation  sutures  have  been 
introduced  the  kidney  is  returned  into  the  abdomen. 

The  ends  of  the  fixation  sutures,  one  after  another,  are  threaded 
in  a  large,  curved,  Hagedorn  needle,  and  carried,  mattress  fashion, 
through  the  muscles  that  correspond  to  the  edges  of  the  incision. 
The  sutures  are  tied  without  drawing  them  too  tight,  and  serve  to 
suspend  the  kidney  by  its  capsule  to  the  edges  of  the  incision. 

There  are  usually  no  large  vessels  encountered  during  the 
operation,  but  all  spurting  points  should  be  clamped  and  ligated. 
The  wound  should  be  perfectly  dry.  No  drainage  is  necessary.  The 
incision  is  closed  by  a  line  of  suture  of  fairly  thick  chromic  catgut, 
which  unites  the  edges  of  the  divided  aponeurosis  of  the  latissimus 
dorsi.     This  suture  is  continuous,  the  stitches  close  together,   and 


OPERATIONS  UPON  THE  KIDNEY.  659 

should  unite  the  edges  of  the  aponeurosis  securely  and  accurately. 
The  edges  of  the  skin  are  approximated  with  a  continuous  suture  of 
plain  catgut. 

For  Perinephritic  Abscess. — Pus  in  the  loose  fat  and  connective 
tissue  around  about  the  kidney.  The  kidney  itself  may  or  may  not 
be  the  site  of  the  primary  infection.  The  patient  is  placed  in  the 
prone  position,  with  the  Edebohls  bag  under  the  abdomen.  The  pres- 
ence of  pus  will  usually  have  already  been  demonstrated  by  the 
exploring  needle. 

The  incision  is  made  as  already  described  in  the  previous  opera- 
tion, exposing  the  edge  of  the  erector  spinas,  quadratus  lumborum, 
etc.  When  the  deep  layer  of  the  lumbar  fascia  is  exposed  a  small 
incision  is  made  through  which  the  pus  escapes,  usually  in  large 
quantity.  This  opening  is  enlarged  with  the  finger,  the  cavity  washed 
out  with  salt  solution  and  packed,  not  too  tightly,  with  iodoform  gauze. 
The  edges  of  the  upper  part  of  the  incision  are  brought  together 
with  several  interrupted  sutures  of  heavy  silk. 

Nephrotomy. — Cutting  into  the  kidney  for  the  purpose  of 
evacuating  an  abscess  or  to  explore  the  pelvis  of  the  kidfj^^li^ 

The  position  of  the  patient  and  the  incision  are  as  described  for 
nephropexy  (page  655),  The  patient  is  placed  prone,  with  the 
Edebohls  cushion  underneath  the  abdomen.  The  incison  is  carried 
down,  step  by  step,  until  the  last  layer  of  the  lumbar  fascia  has  been 
cut  and  the  kidney  is  reached.  If  operating  for  nephritic  abscess, 
we  may  find,  as  soon  as  the  kidney  is  exposed,  that  the  indications 
of  the  abscess  immediately  present  themselves,  or  it  may  be  neces- 
sary to  search  with  an  exploring  needle.  When  pus  is  located,  the 
cavity  containing  it  is  incised  with  the  point  of  the  scalpel  and 
enlarged  with  dressing  forceps,  which  are  introduced  closed  and 
expanded  as  they  are  withdrawn.  At  times  the  entire  kidney  sub- 
stance is  destroyed,  and  simply  a  bag  of  pus  remains.  We  may  or 
may  not  find  a  stone.  The  kidney  may  be  very  firmly  adherent,  so 
that  great  difficulty  would  be  experienced  in  loosening  it  to  bring  it 
up  into  the  incision  for  examination.  Under  these  circumstances  it 
is  probably  wise  not  to  persist  in  the  effort  to  loosen  the  kidney,  but 
to  be  content  with  opening  and  draining  the  abscess. 

The  abscess  cavity  is  irrigated  and  packed  loosely  with  iodoform 
gauze,  the  end  of  which  emerges  through  the  lower  part  of  the  incision 
in  the  loin.  The  incision  is  closed  as  described  in  nephropexy,  first 
the  edges  of  the  aponeurosis  with   heavy,   chromic  catgut  sutures. 


660  URINARY  SYSTEM. 

and  then  the  skin.  The  lower  part  of  the  incision  is  left  open  for 
drainage. 

At  times,  in  order  to  explore  the  pelvis  of  the  kidney  or  to 
drain  it,  it  may  be  necessary  to  bisect  or  split  the  kidney  from  its 
posterior  rounded  border  right  through  into  its  pelvis.  In  doing 
this  care  should  be  exercised  to  divide  the  kidney  a  little  behind  the 
middle  of  the  outer,  rounded  border,  the  section  passing  through  a 
plane  a  little  nearer  the  posterior  surface  than  the  anterior  surface, 
through  the  non-vascular  zone  of  Hyrtl.  There  will  be  much  less 
hemorrhage.  The  kidney  must  be  brought  out  through  the  incision 
in  the  back  for  this  purpose.  It  is  usually  sufficient  if  the  incision 
in  the  kidney  extends  through  only  a  part  of  its  length — through 
its  lower  pole — an  incision  just  large  enough  to  admit  the  finger  will 
suffice  in  many  cases. 

In  this  way  the  pelvis  and  calyces  may  be  explored.  The  ureter 
should  be  palpated  as  far  down  as  possible,  and  may  be  sounded  by 
passing  a  rubber  bougie.  Stones  which  would  otherwise  escape  de- 
tection may  thus  be  discovered  and  removed,  or,  if  there  is  no  stone 
present.^  ^ad  the  symptoms  are  due  to  an  inflammatory  condition  of 
the  pelvis,  this  may  be  drained  through  the  kidney  by  leaving  a  small 
tube  or  a  strip  of  iodoform  gauze,  which  reaches  from  the  pelvis  of 
the  kidney  and  emerges  through  the  incision  in  the  loin.  A  re- 
sulting urinary  fistula  usually  closes  spontaneously,  provided  the 
ureter  is  not  obstructed. 

The  vessels  at  the  hilum  may  be  compressed  in  order  to  avoid 
considerable  loss  of  blood  that  would  necessarily  occur  during  the 
examination  of  the  pelvis,  etc.,  after  the  kidney  has  been  split  open 
for  a  considerable  portion  of  its  length.  The  vessels  may  be  com- 
pressed between  the  finger  and  thumb  of  an  assistant,  or  they  may 
be  compressed  between  the  rubber-sheathed  blades  of  a  clamp.  The 
clamp  must  not  be  applied  too  tight.  For  the  purpose  of  controll- 
ing the  hemorrhage  after  the  examination  has  been  completed,  the 
cut  surfaces  of  the  kidney  are  brought  together  with  several  deep 
sutures  passed  through  the  kidney  substance  from  one  side  to  the 
other.  Tor  these  sutures  plain,  fairly  thick  catgut  is  used.  The 
sutures  are  passed  with  a  large,  curved  surgeon's  needle,  and  should 
not  be  drawn  too  tight  when  they  are  tied.  Occasionally  in  order  to 
control  the  hemorrhage  from  the  kidney  it  may  be  necessary,  in 
addition  to  the  sutures,  to  pack  iodoform  gauze  in  between  the  cut 
surfaces  of  the  kidney. 


OPERATIONS  UPON  THE  KIDNEY.  661 

If  the  kidney  has  been  incised  it  is  wise  to  leave  a  gauze  drain 
in  the  incision  in  the  back  for  at  least  forty-eight  hours. 

Nephrolithotomy. — Cutting  into  the  kidney  for  stone. 

The  steps  of  this  operation  are  like  those  already  described  in  the 
preceding  operation.  iVfter  the  kidney  has  been  reached  and  brought 
up  and  out  through  the  incision  it  may  be  palpated  in  order  to  locate 
the  stone.  The  stone  may  be  found  in  the  pelvis  of  the  kidney,  in 
one  of  the  calyces,  or  in  the  substance  of  the  kidney  near  the  surface. 
The  ureter  should  be  traced  downward  as  far  as  possible,  palpating 
it  between  the  finger  and  thumb.  A  stone  in  the  pelvis  may,  as  a 
rule,  be  readily  detected  when  the  pelvis  is  grasped  between  the 
fingers  and  thumb.  If  a  stone  is  felt  in  the  substance  of  the  kidney 
an  incision  is  made  down  upon  the  stone  and  the  stone  removed.  A 
stone  in  the  pelvis  may  be  removed  by  incising  the  posterior  wall 
of  the  pelvis, — pyelotomy.  The  fat  is  scraped  off  the  posterior  sur- 
face of  the  pelvis — the  blood-vessels  lie  in  front  of  the  pelvis — and 
the  pelvis  incised  and  the  stone  removed.  The  incision  in  the  pelvis 
is  made  from  above  downward,  parallel  with  the  course  of  the  ureter 
and  should  be  large  enough  to  admit  the  finger  for  exploration,  etc. 
This  plan  is  adapted  to  those  cases  where  the  stone  is  small  and  the 
pelvis  free  from  infection.-  The  stone  may  be  removed  from  the 
pelvis  by  incising  the  kidney  as  described  in  the  preceding  operation, 
cutting  through  the  substance  of  the  kidney  from  its  free,  rounded 
border  down  into  the  pelvis.  This  latter  is  the  more  satisfactory 
plan  for  most,  if  not  all,  cases  The  stone  is  removed  with  the  finger, 
forceps  or  scoop.  If  one  is  unable  to  discover  a  stone  by  palpation 
of  the  kidney  tissue,  pelvis,  etc.,  and  the  s^Tuptoms  indicate  that  a 
stone  is  present,  then  the  kidney  should  be  incised  as  described  in 
the  preceding  operation  so  that  the  finger  may  be  introduced  and 
the  interior  of  the  pelvis,  calyces,  etc.,  may  be  explored  for  the  pres- 
ence of  a  stone  or  some  other  condition  in  the  pelvis  to  account  for 
the  symptoms.  The  ureter  should  be  traced  down  as  far  as  possible 
with  the  fingers  and  examined  by  palpation  for  possible  impacted 
stone.  A  rubber  bougie  may  be  passed  through  the  pelvis  of  the 
kidney  into  the  ureter  and  down  through  the  ureter  in  order 
to  test  the  patency  of  its  canal.  A  stone  in  the  ureter  may  be 
stripped  up  into  the  pelvis  and  removed.  As  a  rule  pus  is  associated 
with  stone,  and  it  is  usually  wise,  therefore,  to  drain  the  kidney, 
leaving  a  strip  of  iodoform  gauze  in  the  kidney  for  this  purpose.  If 
there  is  little  or  no  infection  of  the  pelvis  and  the  ureter  is  certainly 


QG2  URINAEY  SYSTEM. 

patent,  the  drainage  may  be  omitted  and  the  incision  in  the  kidney 
closed  with  one  or  more  through  and  through  catgut  sutures.  If  the 
stone  has  been  removed  through  the  pelvis  of  the  kidney  the  incision 
in  the  pelvis  may  be  closed  with  several  plain  catgut  sutures  intro- 
duced with  a  small,  full-curved  needle  in  a  holder.  It  is  well  to 
provide  drainage  for  the  incision  in  the  back,  a  strip  of  gauze  being 
packed  into  the  wound  down  to  the  site  of  the  incision  in  the  kidney 
or  pelvis  of  the  kidney. 

Nephrectomy. — Extirpation  of  the  kidney.  The  kidney  is  re- 
moved for  disease,  malignant,  suppurative,  tuberculous;  for  wounds; 
uncontrollable  hemorrhage,  etc.  If  probable  removal  of  a  kidney  is 
in  question  it  is  necessary  for  the  operator  to  have  assured  himself 
positively  that  the  patient  has  two  kidneys  and  that  the- kidney  which 
is  to  remain  is  capable  of  carrying  on  the  function.  Preliminary 
cystoscopic  examination  of  the  bladder  will  demonstrate  the  presence 
of  two  ureters,  at  least  one  ureteral  opening  on  each  side.  By 
catherization  of  the  ureters  urine  may  be  obtained  from  each  kidney 
separately.  Examination  of  the  urine  thus  obtained  will  indicate 
the  functional  capacity  of  each  kidney. 

The  kidney  can  be  removed  through  an  incision  in  the  lumbar 
region;  or  else  through  an  incision  in  the  anterior  abdominal  wall — 
the  transperitoneal  route. 

Lumbar  Nephrectomy.^ — -This  is  the  preferable  method  for 
removal  of  the  kidney;  the  peritoneal  cavity  is  not  opened.  This 
method  is  applicable  to  practically  all  cases  except  where  the  kidney 
is  very  large  or  where  the  kidney  is  exposed  during  the  course  of  an 
abdominal  exploration. 

The  position  of  the  patient  is  the  same  as  that  already  described 
for  nephropexy.  The  steps  of  the  operation  are  as  above  indicated 
down  to  the  point  of  exposing  the  kidney.  The  incision  is  the  same 
as  that  described  for  nephropexy  (page  655)  and  should  reach  from 
the  last  rib  to  the  crest  of  the  ilium.  If  necessary,  we  may  obtain 
more  room  by  continuing  the  incision  forward,  above  and  parallel 
with  the  crest  of  the  ilium  as  far  as,  or  beyond;  the  anterior  superior 
iliac  spine. 

The  isolation  of  the  kidney  must  be  thorough,  and  this  is  ac- 
complished with  the  hand  in  the  wound,  working  patiently,  with  the 
fingers,  around  the  kidney,  care  being  taken  not  to  tug  upon  the 
kidney,  as  one  may  tear  the  vessels  at  the  hilum.  The  suprarenal 
capsule  may  be  left  behind,  although,  if  diseased,  it  may  be  removed 


OPERATIONS  UPON  THE  KIDNEY.  663 

also.  Occasionally  the  kidney  is  found  to  be  very  adherent  to  the 
adjacent  structures,  and  great  care  and  patience  must  be  exercised 
in  detaching  and  isolating  it.  After  the  kidney  has  been  freed,  all 
around,  it  is  brought  well  up  into  the  incision,  or,  as  may  be  done  in 
most  cases,  the  kidney  is  brought  entirely  out  through  the  incision. 
The  ureter  is  traced  as  far  down  as  possible  and  clamped  with  two 
artery  forceps  and  cut  between  them.  The  stump  of  the  lower  portion 
is  ligated  with  ten-day  chromic  catgut,  the  forceps  removed  and  the 
end  touched  with  pure  carbolic  on  a  probe.  A  heavy,  plain  catgut 
ligature  (No.  3  or  4)  is  tied  around  the  pedicle,  which  consists  of 
the  renal  artery  and  vein.  The  proximal  end  of  the  ureter  which  is 
still  grasped  with  the  artery  clamp  is  held  up  out  of  the  way  so  that 
it  may  not  be  included  in  the  ligature.  The  ligature  must  be  tied 
very  tight,  the  first  loop  of  the  knot  being  double,  so  that  it  cannot 
slip.  The  ends  of  the  ligature  are  left  long  to  serve  as  a  tractor  to 
bring  the  stump  of  the  pedicle  up  into  the  incision  for  final  in- 
spection. In  cutting  away  the  kidney  the  division  should  not  pass 
through  the  pedicle,  which  is  made  of  the  vessels,  but,  if  possible, 
should  pass  through  the  kidney  tissue  near  the  hilum,  in  order  to 
leave  a  little  mass  of  kidney  tissue  as  a  cap,  or  knob,  to  prevent  the 
slipping  of  the  ligature. 

The  wound  is  treated  as  in  the  foregoing  operation.  It  is  prob- 
ably wise  to  introduce  a  drain,  which  is  left  for  forty-eight  hours. 

Abdominal  Nephrectomy. — This  route  is  selected  for  those 
cases  in  which  the  kidney  is  represented  by  a  large  tumor  mass  in 
the  abdominal  cavity.  Occasionally  during  an  exploratory  laparotomy 
for  indefinite  intra-abdominal  injury  the  kidney  is  found  to  be  so 
badly  damaged  that  it  has  to  be  removed. 

The  patient  lies  flat  upon  the  back.  The  incision  is  made 
through  the  middle  of  the  rectus  muscle,  about  four  inches  long,  the 
middle  of  the  incision  corresponding  to  the  level  of  the  umbilicus. 
It  may  be  necessary,  later,  to  lengthen  the  incision.  If  the  kidney 
is  large  it  presents  prominently  into  the  incision.  The  great  omen- 
tum and  transverse  colon  are  pushed  upward  toward  the  diaphragm, 
the  small  intestines  inward  toward  the  middle  line,  and  the  ascend- 
ing or  descending  colon  (according  to  whether  the  right  or  left 
kidney)  outward,  toward  the  outer  part  of  the  abdominal  cavity. 
The  intestines  are  held  thus  out  of  the  way  with  gauze  pads.  The 
kidney  is  covered  upon  its  anterior  surface  by  the  peritoneum.  Pass- 
ing outward,  across  the  front  of  the  kidneys,  behind  the  peritoneal 


664  URINARY  SYSTEM. 

layer,  are  the  arteria  coliea  dextra  across  the  right  kidney  and  the 
arteria  coliea  sinistra  across  the  left.  If  the  kidney  is  not  consider- 
ably increased  in  size  it  will  be  necessary  to  seek  for  it  in  its  proper 
position,  in  the  upper,  back  part  of  the  abdomen. 

In  order  to  expose  the  kidney  it  is  necessary  to  incise  the  peri- 
toneal layer  that  covers  its  anterior  surface.  This  should  be  done 
bluntly,  tearing  with  the  finger-nail  or  forceps  or  the  blunt  end  of 
a  scissors  in  order  not  to  injure  the  coliea  artery  and  vein  which  pass 
across  the  front  of  the  kidney  to  reach  the  ascending  or  descending 
colon.  After  the  peritoneal  layer  has  been  opened  the  kidney  may 
be  freed  all  around,  working  with  the  hand  close  to  the  kidney  sur- 
face in  the  pocket  in  which  it  is  lodged,  until  the  organ  can  be  lifted 
up  out  of  the  abdominal  incision.  The  fat  and  connective  tissue 
about  the  hilum  are  scraped  away.  The  pedicle  is  seen  to  consist  of 
the  renal  artery  and  vein  and  the  ureter.  The  ureter  may  be  palpated 
as  the  lowest  of  the  three  structures  forming  the  pedicle  and  may 
be  traced  downward  for  some  distance  toward  the  bladder.  The 
ureter  is  followed  downward  toward  the  bladder  as  far  as  possible, 
when  it  is  clamped  with  two  hgemostats  and  divided  between  these. 
The  end  of  the  distal  portion  is  tied  off  with  ten-day  chromic  catgut, 
the  clamp  removed  and  the  end  of  the  stump  touched  with  pure 
carbolic  acid  on  a  probe.  The  ends  of  the  ligature  are  cut  short  and 
the  stump  dropped  into  the  abdomen.  A  heavy,  plain  catgut  ligature 
(No.  3)  is  thrown  around  the  pedicle  of  the  kidney — renal  artery 
and  vein — ^but  not  including  the  ureter,  and  the  ligature  tied. 
This  ligature  must  be  tied  very  tight,  the  first  loop  double,  so  that, 
when  the  kidney  is  cut  away,  the  ligature  will  not  pull  off.  Too 
much  traction  must  not  be  made  upon  the  ligature  while  the  kidney 
is  being  cut  away.  In  cutting  the  kidney  away  from  the  pedicle, 
cut  as  far  away  from  the  ligature  as  possible  so  as  to  leave  a  little 
cap  of  tissue  to  prevent  the  ligature  from  slipping  off. 

In  closing,  if  the  case  has  been  a  clean  one,  the  edges  of  the  torn 
peritoneum  corresponding  to  the  pocket  out  of  which  the  kidney  has 
been  removed,  are  sutured  together  with  a  few  stitches  of  plain  catgut 
and  the  incision  in  the  abdominal  wall  then  closed  without  drainage. 
If  the  operation  has  been  done  for  a  septic  or  tuberculous  condition  it 
will  be  necessary  to  drain  the  pocket  out  of  which  the  kidney  has 
been  enucleated.  This  pocket  may  be  drained  by  sewing  its  edges 
to  the  edges  of  the  abdominal  incision,  leaving  the  latter  open  in 
part  and  introducing  a  plug  of  strip  gauze;    or  the  pocket  may  be 


OPERATIONS  UPON  THE  KIDNEY.  665 

draiDed  by  making  an  incision  in  the  lumbar  region,  cutting  down 
upon  the  blunt  point  of  a  dressing  forceps  which  is  introduced 
from  within.  A  plug  of  strip  gauze  is  passed  from  the  pocket  out 
through  the  incision  in  the  back  and  the  edges  of  the  peritoneal  pocket 
then  imited  with  a  catgut  suture.  The  abdominal  incision  may  then 
be  closed  without  drainage. 

Decortication  of  the  Kidney  (Edebohls). — This  operation  was 
first  suggested  for  the  cure  of  chronic  Bright's  disease,  by  Edebohls. 
The  real  value  of  the  procedure  in  this  condition  is  still  undeter- 
mined. Whatever  beneficial  effect  it  may  have  is,  no  doubt,  due  to 
the  increased  supply  of  blood  that  is  brought  to  the  kidney  through 
the  new  vascular  connections  that  are  formed  between  it  and  the 
adjacent  parts.  The  splitting  of  the  dense,  non-yielding  capsule  of 
the  kidney  relieves  the  tension  and  compression  exercised  upon  the 
kidney  tissue,  and  oftentimes  results  in  the  cure  of  certain  forms  of 
hemorrhage  from  the  kidney  and  of  nephralgia. 

Xitrous  oxide  and  oxygen  with  a  minimum  amount  of  ether  is 
a  satisfactory  anesthetic  mixture  for  these  cases.  Spinal  analgesia 
would,  no  doubt,  be  appropriate  in  some  cases  where  the  condition  of 
the  patient  is  such  as  to  counterindicate  the  use  of  a  general  anaes- 
thetic. 

The  patient  lies  prone  upon  the  table  with  an  Edebohls  rubber 
cushion  under  the  abdomen.  The  incision  is  the  same  as  that 
described  for  nephropexy  and  corresponds  to  the  edge  of  the  erector 
spinae,  quadratus  lumborum,  etc.  The  kidney  is  recognized  in  the 
mass  of  fat,  fatty  capsule,  that  incloses  it. 

With  the  fingers  in  the  wound  the  fatty  capsule  is  separated 
bluntly  from  the  surface  of  the  kidney  as  far  as  the  pelvis.  The 
kidney,  inclosed  within  its  own  proper  fibrous  capsule,  is  then  drawn 
up  and  out  through  the  incision,  upon  the  back. 

Corresponding  to  the  middle  of  the  outer,  rounded  border  of  the 
kidney,  the  capsule  proper  is  .incised  and  divided  upon  a  director 
along  the  entire  length  of  the  outer,  rounded  border  of  the  organ,  and 
around  its  extremities,  above  and  below.  Each  half  of  the  capsule  is 
then  stripped  away  from  the  surface  of  the  kidney  toward  the  pelvis, 
taking  care  not  to  break  or  tear  the  kidney  substance  proper,  which 
may  be  friable  and  firmly  adherent  to  the  capsule.  The  stripped-off 
capsule  is  finally  cut  away  near  the  pelvis  of  the  kidney,  and  removed. 
Any  portion  of  the  capsule  that  still  remains  may  be  rolled  back 
toward  the  pelvis  of  the  kidney,  where  it  remains  coiled  up,  upon 
itself. 


QQQ  URINARY  SYSTEM. 

The  kidney  is  finally  replaced  in  the  abdomen,  and  the  incision 
closed  without  drainage.  At  the  time  of  operation  it  may  appear  that 
but  one  kidney  is  the  seat  of  chronic  Bright's  disease,  but  it  is  prob- 
ably wise  in  all  cases  to  decapsulate  both  kidneys  at  the  same  sitting. 

OPERATIONS  UPON  THE  URETER. 

Ureterolithotomy. — Incision  into  the  ureter  for  the  removal  of 
a  calculus.  Calculi  escape  from  the  pelvis  of  the  kidney  into  the 
ureter.  Small  stones  may  pass  on  through  the  ureter  and  escape 
into  the  bladder.  Larger  stones  may  become  impacted  in  the  ureter 
and  wedged  tight  and  thus  block  the  ureter  permanently  and  com- 
pletely, or  they  may  shift  their  position,  now  and  then,  '^ball-valve" 
fashion,  in  a  dilated  portion^  of  the  ureter,  and  thus  occasionally  allow 
the  urine  to  flow  past  them.  The  ureter  becomes  dilated  and  its  wall 
thickened  behind  the  obstruction.  The  pelvis  of  the  kidney  becomes 
dilated  (hydronephrosis),  and  if  the  elements  of  infection  are  added 
we  have  a  condition  of  pyonephrosis. 

The  diagnosis  of  stone  in  the  ureter  is  very  materially  aided  by 
the  X-ray  and  by  the  introduction  of  a  wax-tipped  catheter  into  the 
ureter.  The  wax-tip,  examined  under  the  magnifying  glass,  will  show 
minute  scratches  caused  by  contact  with  the  calculus. 

The  ureter  may  be  approached  through  the  retroperitoneal  route, 
or  it  may  be  exposed  by  entering  the  a,bdominal  cavity  from  in  front 
and  incising  the  peritoneal  layer  that  covers  it, — the  transperitoneal 
route.    The  former  is  by  far  the  preferable  method. 

Eetropeeitoneal  Method. — The  patient  lies  flat  upon  the  back. 
An  incision  is  made  which  reaches  from  near  the  tip  of  the  twelfth 
rib  to  a  point  about  one  inch  above  the  anterior  superior  iliac  spine. 
If  more  room  is  necessary  the  incision  may  be  continued  forward  and 
inward,  above  and  parallel  with  Poupart's  ligament  as  far  as  the 
middle  of  the  ligament.  The  incision  divides  the  various  layers  down 
to  the  peritoneum.  The  peritoneum  is  not  incised.  If  the  peritoneum 
is  opened  accidentally,  the  opening  should  be  closed  immediately 
with  a  continuous  catgut  suture.  The  peritoneal  layer  is  peeled  up, 
away  from  the  posterior  wall  of  the  abdomen,  working  inward  toward 
the  middle  line  until  the  psoas  muscle  is  reached.  As  the  peritoneal 
layer  is  lifted  up,  away  from  the  psoas  muscle,  the  ureter  is  likely  to 
go  with  the  peritoneal  layer,  since  it  is  quite  intimately  attached  to 
the  peritoneum.  The  ureter  dips  down  into  the  pelvic  cavity  over 
the  brim  of  the  pelvis,  passing  across  the  bifurcation  of  the  common 


OPERATIONS  UPON  THE  URETER.  667 

iliac  or  the  commencement  of  the  external  iliac.  The  ureter  is 
readily  recognized  if  it  contains  a  stone  and  if  it  is  dilated  and  its 
wall  thickened.  The  identification  of  the  ureter  is  greatly  facilitated 
if  a  catheter  has  been  previously  passed  up  into  it  through  the 
bladder  with  the  aid  of  the  cystoscope.  A  longitudinal  incision  is 
made  in  the  ureter  and  the  stone  removed.  Before  the  incision  is 
made  the  ureter  is  seized  with  a  rubber-sheathed  clamp  well  above 
the  location  of  the  stone,  in  order  to  prevent  escape  of  urine  when 
the  ureter  is  opened.  The  incision  is  made,  not  directly  over  the 
calculus,  but  rather  above  the  location  where  the  stone  is  impacted, 
where  the  ureter  is  likely  to  be  more  or  less  dilated.  The  lumen  of 
the  ureter  is  investigated  with  a  probe  or  bougie  for  the  presence 
of  additional  stones  and  to  test  its  patency.  The  incision  in  the 
ureter  is  closed  with  several  sutures  of  fine,  chromic  catgut,  in  a  fine, 
curved  needle.  These  sutures  should  not  penetrate  the  entire  thick- 
ness of  the  wall  of  the  ureter;  they  should  not  appear  within  the 
lumen  of  the  tube.  If  any  difficulty  is  experienced  in  introducing 
the  sutures  they  may  be  omitted  because  the  incision  in  the  ureter 
heals  without  diflficulty  provided  the  ureteral  canal  is  patent.  A 
plug  of  strip  gauze  is  left  in  the  incision,  reaching  down  to  the 
incision  in  the  ureter  to  provide  for  drainage  in  the  event  of  leakage. 
The  incision  in  the  abdomen  is  closed  with  interrupted,  deep  sutures 
of  silk-worm  gut  except  where  the  gauze  drain  emerges. 

Transperitoneal  Eoute. — An  incision  is  made  in  the  anterior 
abdominal  wall — through  the  middle  of  the  rectus  muscle.  The  in- 
testines are  pushed  aside  and  held  out  of  the  way  with  gauze  pads. 
The  ureter  is  found  behind  the  peritoneal  layer,  resting  upon  the 
psoas  muscle  and  dipping  into  the  pelvic  cavity  across  the  bifurcation 
of  the  common  iliac  artery.  The  peritoneal  layer  is  incised,  the 
ureter  opened,  and  the  stone  removed.  The  opening  in  the  ureter 
is  accurately  closed  with  a  sufficient  number  of  non-penetrating 
sutures  of  fine  chromic  catgut.  The  incision  in  the  peritoneal  layer 
that  covers  the  ureter  is  also  sutured.  A  cigarette  drain  is  left  in 
the  abdomen  reaching  down  to  the  site  of  the  opening  in  the  ureter. 
Satisfactory  drainage  may  be  provided  by  making  an  incision  in 
the  skin,  behind,  in  the  lumbar  region,  and  poking  a  dressing  forceps 
through  from  within  the  abdomen,  through  the  muscles  of  the  lumbar 
region.  Strip  gauze  may  be  dra^\Ti  through  and  thus  drain  the  site 
of  the  incision  in  the  ureter.  Under  these  circumstances  the  incision 
in  the  anterior  abdominal  wall  may  be  closed  without  drainage. 


668 


URINARY  SYSTEM. 


A  stone  impacted  in  the  lower  end  of  the  ureter,  at  or  near  the 
vesical  orifice  may  be  removed,  in  the  male,  through  a  supra-pubic 
cystotomy.  The  ureteral  orifice  may  be  incised  if  necessary  in  order 
to  reach  the  stone.  In  females  stones  impacted  in  the  lower  part  of 
the  ureter  may  be  removed  through  an  incision  in  the  wall  of  the 
vagina.  The  ureter  is  thus  exposed  and  incised  and  the  stone 
removed. 

ABC 


Fig.  301.— Uretero-ureterostomy  (Van  Hook).  A.  The  end  of  the  upper  renal 
segment  is  incised  and  the  corners  rounded  off.  The  lower,  vesical  segment  of 
the  ureter  has  been  ligated  and  an  incision  made  in  it  near  the  end.  B.  The  end 
of  the  upper  segment  is  drawn  into  the  incision  in  the  lower  segment  with  the 
tractor  suture.  C.  The  end  of  the  upper  segment  has  been  drawn  into  the 
incision  in  the  lower,  vesical  segment  and  fixed  in  position  by  tying  the  tractor 
suture.  A  row  of  sutures  is  applied  which  unites  the  implanted  end  of  the 
upper  segment  to  the  edges  of  the  incision  in  the  lower  vesical  segment. 


■Uretero-Tireterostomy,  End-to-side  Anastomosis  (Van  Hook). 
— This  operation  is  done  for  the  purpose  of  restoring  the  ureteral 
canal.  The  lower,  vesical  end  of  the  ureter  is  found  and  ligated. 
About  one-quarter  of  an  inch  below  the  ligatured  end  a  longitudinal 
incision  is  made  in  the  ureter.  This  incision  is  equal  in  length  to 
twice  the  diameter  of  the  ureter.  The  upper,  renal  end  of  the  divided 
ureter   is   secured    and  its   end   incised,   notched,    for    a    short    dis- 


OPERATIONS  UPON  THE  URETER. 


669 


tance,  about  one-quarter  inch,  and  the  corners  of  the  incision  then 
rounded  off. 

A  fine,  straight  needle  is  threaded  in  each  end  of  a  fine,  plain 
catgnt  suture.  This  suture  secures  the  end  of  the  upper,  renal  seg- 
ment of  the  ureter,  quite  close  to  its  edge  and  at  a  point  opposite 
where  the  notch  has  been  cut  in  it.  This  stitch  does  not  penetrate 
into  the  lumen  of  the  ureter.  The  two  needles  are  passed  into  the 
lower,  vesical  segment  of  the  ureter,  through  the  slit  that  has  been 
made  in  it  and  then  out  through  the  wall  of  the  ureter  Just  beyond 
the  distal  end  of  the  slit.     When  traction  is  made  with  the  suture 


Fig.  302.— L'retero-ureterostomy  (Bovee).  A.  The  ends  of  the  ureter  cut 
obliquely.  Four  sutures  introduced  which  do  not  penetrate  through  entire 
thickness  of  wall  of  ureter.  B.  The  sutures  tied  and  the  ends  of  the  divided 
ureter  joined  together.    Additional  sutures  may  be  introduced  as  necessary. 


the  open  end  of  the  upper,  renal  segment  of  the  ureter  is  drawn  into 
the  slit  which  has  been  made  in  the  side  of  the  lower,  vesical  seg- 
ment. The  suture  is  tied  and  the  end  of  the  ureter  thus  secured  in 
position.  A  continuous  suture  of  very  fine  silk  is  applied,  which 
secures  to  the  edges  of  the  incision  in  the  lower,  vesical  segment  to 
the  end  of  the  implanted,  renal  segment. 

End-to-end  Anastomosis  (Bovee). — The  two  ends  of  the 
ureters  are  cut  obliquely  to  allow  for  subsequent  contraction,  and  are 
then  joined  together  with  non-penetrating  sutures  of  fine  silk  placed 
fairly  close  together. 

Uretero-Cystostomy. — Implantation  of  the  end  of  the  ureter  into 
the  bladder.  The  ureter  will  usually  have  been  damaged  or  caught 
in  a  ligature  during  a  hysterectomy. 


670  URINARY  SYSTEM. 

The  bladder  is  moderately  distended  with  boric  acid  solution 
and  the  abdominal  cavity  is  opened  through  an  incision  in  the  anterior 
abdominal  wall. 

The  ureter  is  sought  for  where  it  dips  into  the  pelvic  cavity  at 
the  brim  of  the  pelvis  and  is  exposed  by  incising  the  peritoneal  layer 
which  covers  it.  Traction  is  made  upon  the  ureter  to  indicate  its 
further  course  and  position  in  the  pelvic  cavity.  An  incision  is  made 
in  the  peritoneum  covering  the  ureter  as  low  down,  as  near  the 
bladder,  as  possible  and  the  ureter  thus  exposed.  A  chromic  catgut 
ligature  is  tied  around  the  ureter  low  down,  near  the  bladder  end. 


Fig.  303.— Uretero-cystostomy.  Vesical  end  of  ureter  ligated  close  to  the 
bladder.  The  end  of  the  ureter  is  drawn  into  the  small  incision  in  the  bladder 
■with  a  tractor  suture. 

The  ureter  is  secured  with  a  rubber-sheathed  clamp  just  above  the 
ligature,  and  then  divided  between  the  ligature  and  the  clamp. 

A  small  incision  is  made  in  the  bladder  as  near  the  original  site 
of  the  ureteral  orifice  as  possible.  This  incision  is  made  upon  the 
point  of  a  metal  sound  which  is  introduced  into  the  bladder  through 
the  urethra.  The  end  of  the  ureter  is  incised,  notched,  for  a  short 
distance,  and  the  corners  rounded  off  to  provide  for  possible  sub- 
sequent contraction  of  the  orifice.  A  guiding  or  traction  suture  of 
fine  catgut  is  introduced  which  secures  the  end  of  the  ureter  in  a 
manner  similar  to  that  employed  in  the  Van  Hook  operation 
described  above.  The  needles  carrying  the  tails  of  the  traction  suture 
are  introduced  into  the  bladder  through  the  opening  which  has  been 
made,  and  then  out  through  the  wall  of  the  bladder  just  beyond  the 


SURGICAL  ANATOMY  OF  THE  BLADDER. 


671 


edge  of  the  incision.  When  the  suture  is  drawn  taut  it  pulls  the 
end  of  the  ureter  into  the  incision  in  the  bladder.  The  suture  is 
tied  and  the  edges  of  the  incision  in  the  bladder  sewed  all  around 
to  the  end  of  the  implanted  ureter  with  interrupted  sutures  of  fine 
silk.  The  ureter  for  about  one  inch  of  its  length  is  then  buried 
beneath  two  folds  of  the  bladder  wall,  which  are  sutured  over  it  in 
a  manner  similar  to  that  used  in  the  Witzel  gastrostomy. 

Uretero-Enterostomy. — One  or  both  ureters  may  be  implanted 
into  the  bowel — usually  into  the  sigmoid  flexure.  This  operation  is 
sometimes  done  for  exstrophy  of  the  bladder.  There  is  danger  of 
infection  traveling  up  the  ureters  and  involving  the  kidneys.    If  the 


Fig.  304. — Uretero-cystostomy.    The  bladder  wall  is  raised  in  two  folds  and 
sutured  over  the  end  of  the  ureter. 

portion  of  the  bladder  wall  immediately  adjacent  to  the  ureteral 
orifices  is  resected  with  the  ureters  in  order  to  retain  the  sphincter- 
closing  apparatus,  and  this  piece  carrying  the  two  ureteral  orifices 
then  sutured  into  the  intestine  there  will  be  less  danger  of  infectious 
elements  gaining  entrance  to  the  ureters  and  affecting  the  kidneys. 


THE  BLADDER. 

Surgical  Anatomy  of  the  Bladder. — The  bladder  is  a  hollow  mus- 
cular organ  whose  function  is  to  receive  and  hold  the  urine  during 
the  intervals  of  micturition.  It  has  a  capacity  ordinarily  of  about 
sixteen  ounces.  In  the  contracted  state  the  wall  of  the  bladder  is 
seen  to  be  quite  thick. 

In  the  infant  the  bladder  is  rather  conical,  and  projects  into  the 
abdomen  above  the  level  of  the  symphysis. 


672  URINARY  SYSTEM. 

In  the  adult  the  bladder,  when  empty,  lies  deep  within  the  pelvis 
behind  the  symphysis,  its  cavity  obliterated  and  its  walls  collapsed 
and  in  contact  with  each  other.  When  distended  moderately,  it 
reaches  as  high  as  the  symphysis,  farther  distension  causing  it  to  rise 
up,  out  of  the  pelvis,  into  the  abdominal  cavity  a  varying  distance 
toward  the  umbilicus.  When  it  is  distended  with  about  a  pint  of 
fluid,  the  bladder  is  pear-shaped,  and  reaches  for  a  distance  of  about 
four  inches  above  the  symphysis. 

The  body  of  the  bladder  is  free,  and,  when  the  organ  is  distended, 
rises  out  of  the  pelvis  into  the  abdomen,  toward  the  umbilicus. 

The  base  of  the  bladder  in  the  male  is  in  close  relation  with  the 
anterior  surface  of  the  upper  part  of  the  rectum,  and  upon  its  inner 
aspect,  on  either  side,  shows  the  openings  of  the  ureters. 

The  neck  of  the  bladder  is  continuous  with  the  commencement 
of  the  urethra,  and  in  the  male  the  prostate  surrounds  it  like  a 
collar. 

Relations  of  the  Bladder.  In  the  Male  the  bladder  is  in  rela- 
tion, behind,  with  the  rectum,  the  base  of  the  bladder  lying  directly 
in  front  of  the  upper  portion  of  this  part  of  the  bowel,  the  two  being 
joined  together  more  or  less  intimately  by  connective  tissue. 

The  seminal  vesicles  and  vas  deferens  are  located  on  either  side 
of  the  middle  line,  in  the  space  between  the  contiguous  walls  of  the 
rectum  and  the  bladder;  they  converge  anteriorly  and  join  to  form 
the  two  common  ejaculatory  ducts  which  enter  the  prostate  gland 
at  the  base.  The  prostate  gland  is  readily  palpable  through  the 
rectum,  above  the  anal  portion. 

In  the  Female  the  uterus  and  vagina  are  located  behind  the 
bladder. 

In  both  sexes  the  bladder  lies  immediately  behind  the  symphysis 
pubis,  from  which  it  is  separated  by  a  space,  which  is  filled  with  loose 
connective  tissue  more  or  less  firmly  connected  with  the  anterior  wall 
of  the  bladder,  and  which  is  called  the  space  of  Retzius.  When  the 
bladder  is  distended  it  reaches  above  the  symphysis  and  is  then  in 
relation,  in  front,  with  the  anterior  abdominal  wall. 

Passing  from  the  summit  of  the  bladder  to  the  umbilicus  is  the 
urachus,  which  occasionally  remains  patent  after  birth. 

The  peritoneum  covers  the  sides,  part  of  the  posterior  surfaces, 
and  the  summit  of  the  bladder,  but  does  not  cover  its  anterior  surface, 
being  reflected  from  the  summit  of  the  bladder  over  on  to  the  poste- 
rior surface  of  the  anterior  abdominal  wall.     When  the  bladder  is 


SURGICAL  ANATOMY  OF  THE  BLADDER. 


673 


well  distended,  it  rises  upward  into  the  al)domen;  its  summit,  as  it 
approaches  the  umbilicus,  carries  the  peritoneum  with  it  and  its  ante- 
rior surface,  which  is  devoid  of  peritoneum,  then  comes  into  relation 
with  the  abdominal  wall;  so  that  under  these  circumstances  the  blad- 
der may  be  entered  through  an  incision  in  the  anterior  abdominal 
wall,  low  down,  close  to  the  symph3^sis,  without  molesting  the  peri- 
toneum or  entering  the  peritoneal  cavity. 


Fig.  .305. — An  Antero-posterior  Section  Showing  Relations  of  the  Peritoneum 
to  the  Bladder,  etc.  Bladder  moderately  distended.  P.,  prostate  gland  sur- 
rounding commencement  of  the  urethra  (neck  of  the  bladder),  course  of  the 
ejaculatory  duct;   T.S.,  vesiculse  seminales. 


The  higher  the  bladder  ascends  into  the  abdomen,  the  larger  the 
area  of  its  anterior,  non-peritoneal  surface  which  is  presented  for 
operation. 

The  Interior  of  the  Bladder. — In  the  contracted  state  the 
wall  of  the  bladder  is  seen  to  be  very  thick,  and  the  cavity  is  prac- 
tically obliterated,  the  walls  being  almost  in  direct  contact  with  each 
other.     The  mucous  lining  of  the  bladder  is  but  loosely  connected 

43 


674  URINARY  SYSTEM. 

with  the  muscular  coat  by  a  loose^  elastic,  submucous  layer,  alnd  in 
the  contracted  state  is  thrown  into  numerous  folds  and  rugse.  The 
floor  of  the  bladder  presents  a  triangular  area  which  is  smooth,  devoid 
of  rugae,  and  which  is  more  firmly  attached  to  the  muscular  coat. 
This  smooth,  triangular  area  is  called  the  trigonum.  It  represents 
an  equilateral  triangle,  the  sides  of  which,  in  the  contracted  state 
of  the  bladder,  measure  about  one  inch  in  length.  The  apex  of  the 
triangle  is  above  at  the  urethral  orifice.  The  base  is  indicated  by  a 
line  drawn  between  the  ureteral  orifices.  Corresponding  to  the  line 
between  the  ureteral  orifices  there  is  a  smooth  elevation  or  bar  which 
is  caused  by  the  presence  in  this  position  of  a  bundle  of  muscular 
fibers  which  pass  transversely  underneath  the  mucous  layer.  This 
elevation  is  slightly  curved  so  as  to  be  convex  forward  and  is  called 
the  torqis  uretericus.  The  ureters  pierce  the  wall  of  the  bladder  very 
obliquely.  The  orifices  of  the  ureters  are  minute,  elliptical  in  shape. 
The  mucous  membrane  corresponding  to  the  outer  edge  of  each  ure- 
teral orifice  is  raised  in  a  thin,  semilunar,  valve-like  fold  which 
effectually  prevents  fluid  backing  up  into  the  ureters  when  the  bladder 
is  distended. 

When  the  bladder  is  distended  the  ureters  get  to  lie  farther 
apart — separated  from  each  other  for  a  distance  of  one  and  one-half 
inches  or  more. 

OPERATIONS  UPON  THE  BLADDER. 

Suprapubic  Cystotomy. — The  bladder  is  opened  through  an  inci- 
sion above  the  pubes.  This  plan  permits  ready  removal  of  calculi 
and  thorough  exploration  of  the  bladder,  removal  of  tumors,  access 
to  the  prostate,  etc. 

The  patient  is  placed  in  the  usual  laparotomy  position,  upon  the 
back,  and  fully  anaesthetized  so  as  to  relax  the  abdominal  muscles. 
A  soft  rubber  catheter  is  introduced  into  the  bladder,  and,  through 
this,  the  bladder  is  washed  out  with  boric-acid  solution,  10  to  12 
ounces  being  allowed  to  remain;  the  catheter  is  then  withdrawn,  and 
a  band  tied  about  the  penis  to  prevent  the  escape  of  the  fluid.  The 
fluid  which  is  thrown  into  the  bladder  causes  it  to  ascend  into  the 
abdomen,  carrying  the  peritoneum  with  it;  so  that  the  anterior 
surface  of  the  bladder,  uncovered  by  peritoneum,  is  exposed  for 
several  inches  for  operation.  Some  advantage  is  gained  if  the  table 
is  tilted  somewhat  so  that  the  patient  occupies  the  Trendelenburg 
position  to  a  moderate  degree. 


OPERATIONS  UPON  THE  BLADDER.  675 

The  incision,  which  is  placed  in  the  middle  line,  linea  alba, 
commences  below,  at  the  symphysis  pubis,  and  reaches  upward,  to- 
ward the  umbilicus,  for  a  distance  of  about  three  inches  and  extends 
through  the  skin  and  fat  down  to  the  deep  fascia.  Bleeding  vessels 
in  the  skin  are  clamped. 

The  incision  is  carried  down  through  the  linea  alba,  between  the 
edges  of  the  recti  and  pyramidales,  until  the  layer  of  connective  tissue 
which  is  found  in  front  of  the  bladder  is  reached.  The  edges  of  the 
incision  are  drawn  apart  with  retractors  and  the  finger  poked  into 
the  incision  and  down  behind  the  symphysis  pubis  so  that  the 
posterior  surface  of  the  symphysis  can  be  plainly  felt  and  recognized. 
The  layer  of  connective  tissue  which  covers  the  anterior  wall  of 
the  bladder  is  scraped  upward,  toward  the  umbilicus,  with  the  finger- 
nail ;  so  that,  in  case  the  fold  of  peritoneum  reaches  abnormally  low, 
or  the  bladder  has  not  been  sufficiently  distended,  we  may  thus  still 
separate  it  and  carry  it  upward  toward  the  umbilicus.  The  smooth 
muscular  wall  of  the  bladder  is  then  easily  recognized,  especially  if 
the  organ  is  distended.  The  distended  organ  that  lies  immediately 
posterior  to  the  symphysis  cannot  be  anything  else  but  the  bladder. 
A  plexus  of  veins,  more  or  less  visible,  which  ascends  upon  the 
anterior  wall  of  the  bladder  from  below,  may  help  still  further  to 
identify  the  bladder. 

With  a  curved  surgeon's  needle  two  sutures  of  plain  catgut  are 
introduced,  one  on  either  side  of  the  middle  line,  through  the  whole 
thickness  of  the  bladder  wall  and  these  are  used  as  tractors  to  steady 
the  bladder  while  it  is  being  incised. 

In  cutting  into  the  bladder  the  point  of  the  knife  is  introduced 
between  the  two  catgut  stitches  about  one  inch  above  the  symphysis 
and  the  bladder  incised  in  a  direction  downward,  toward  the  sym- 
physis. When  the  bladder  is  opened  the  fluid  contained  within  it 
escapes  in  part.  The  incision  should  be  large  enough  to  permit  the 
introduction  of  one  or  two  fingers  for  the  purpose  of  exploration,  etc. 

The  incision  in  the  bladder  may  be  enlarged  sufficiently  to  allow 
necessary  manipulation.  Caution  should  be  exercised  in  extending 
the  opening  in  the  bladder,  in  an  upward  direction,  toward  the 
umbilicus  for  any  considerable  distance,  to  draw  the  fold  of  peri- 
toneum upward  out  of  the  way. 

If  a  stone  is  present,  it  may  be  removed  with  the  forceps,  guided 
by  the  finger ;  if  the  stone  is  very  large,  it  may  first  be  crushed.  One 
should   search   the  bladder   carefullv  for   stones  which  have  become 


(37G  URINARY  SYSTEM. 

almost  completel}^  encysted  in  the  pockets  in  the  bladder  wall.  If  the 
operation  is  done  for  ulcer  of  the  bladder,  the  diseased  area  may  be 
scraped  or  cauterized,  etc.  With  the  patient  in  the  Trendelenburg 
position  and  the  edges  of  the  wound  drawn  asunder  with  broad  re- 
tractors, the  interior  of  the  bladder  may  be  illuminated  and  made 
visible.  A  tumor  may  be  excised  or  an  hypertrophied  prostate  may 
be  enucleated  through  the  suprapubic  opening. 

It  is  wise,  in  all  cases  of  suprapubic  cystotomy,  to  drain  the 
bladder.  For  this  purpose  a  large  rubber  tube  is  introduced  and 
fixed  to  the  edge  of  the  incision  in  the  bladder  by  carrying  the  cor- 
responding catgut  tractor  suture  through  the  tube  with  a  needle. 
The  suture  is  tied  and  fixes  the  tube  so  that  it  cannot  escape  from 
the  bladder.  The  rubber  tube  should  be  one-half  to  three-quarter 
inch  in  diameter.  The  end  which  presents  into  the.  bladder  should 
be  smooth  and  rounded  and,  besides  the  hole  in  the  end,  there  should 
be  a  second  in  the  side  of  the  tube  near  the  end.  The  tube  should 
not  present  into  the  bladder  for  more  than  one  to  one  and  one-half 
inch  of  its  length.  If  the  incision  in  the  bladder  is  quite  large  it  may 
be  sutured  in  part  so  as  to  close  it  fairly  snugly  about  the  rubber 
tube.  The  sutures  of  chromic  catgut  (No.  1  or  2)  which  approxi- 
mate the  edges  of  the  incision  in  the  bladder  should  penetrate  through 
all  the  layers  of  the  bladder  wail  except  the  mucous  coat.  They 
should  not  present  within  the  cavity  of  the  bladder  (see  Fig.  37) .  The 
incision  in  the  abdominal  wall  is  left  open  for  part  of  its  extent  and,  is 
packed  with  iodoform  gauze.  The  gauze  pack  reaches  down  around  the 
tube  to  the  incision  in  the  bladder,  and  also  down  into  the  space  behind 
the  sj^mphysis,  between  the  symphysis  and  bladder, — the  space  of 
Eetzius.  The  tube  from  the  bladder  is  connected  with  another  tube 
which  reaches  over  the  side  of  the  bed  into  a  bottle  partly  filled  with 
some  antiseptic  solution.  The  urine  is  drained  from  the  bladder 
through  the  tube  into  the  bottle.  If  the  tube  becomes  blocked  a  small 
quantity  of  fluid  may  be  injected  through  it  into  the  bladder,  and 
the  tube  then  stripped  with  the  fingers  to  start  the  flow  by  siphonage. 
The  gauze  packing  is  changed  as  often  as  necessary  and  -the  drainage- 
tube  removed,  as  a  rule,  after  six  or  seven  days.  The  suprapubic 
opening  closes  spontaneously  shortly  after  the  tube  has  been  re- 
moved, provided  there  is  no  obstruction  along  the  course  of  the 
urethral  canal. 

Pimcture  of  the  Bladder  may  be  made  in  the  middle  line  just 
above  the  S}Tnphysis.     It  is  done  for  the  purpose  of  drawing  off  the 


SURGICAL  ANATOMY  OF  THE  PENIS.  G77 

urine  when  the  patient  is  unable  to  empty  the  bladder  through  the 
urethra.  One  should  first  satisfy  himself  by  percussion,  etc.,  that  the 
bladder  is  actually  distended. 

A  medium-sized  curved  troehar  is  introduced  above  the  symphy- 
sis; it  should  be  thrust  through  the  anterior  abdominal  wall  in  the 
middle  line  just  above  the  symphysis,  and  in  a  direction  backward  and 
downward,  toward  the  sacrum,  for  a  distance  of  two  or  three  inches. 

THE  PENIS. 

Surgical  Anatomy  of  the  Penis. — The  penis  when  erect  is  pris- 
moid  in  shape.  It  is  composed  of  the  corpora  cavernosa  and  the 
corpus  spongiosum. 

The  corpora  cavernosa  are  two  cylinders  of  erectile  tissue  which 
run  parallel  with  each  other  and  occupy  the  upper  part  of  the  organ. 
They  consist  of  a  mesh-work  of  vasciilar  spaces,  which  may  readily 
become  distended  with  blood,  thus  bringing  the  penis  into  a  con- 
dition of  erection.  They  are  each  provided  with  a  strong,  fibrous 
envelope,  the  tunica  albuginea,  and  behind,  diverge,  to  be  attached 
to  the  rami  of  the  pubes. 

The  corpus  spongiosum  also  consists  of  erectile  tissue,  and  is 
situated  below  the  corpora  cavernosa  forming  the  under  part  of  the 
penis.  The  urethra  passes  through  the  corpus  spongiosum.  The  end 
of  the  penis  is  enlarged,  rather  bulbous,  and  is  known  as  the  glans; 
this  is  really  the  enlarged  extremity  of  the  corpus  spongiosum.  Be- 
hind, in  the  perineum,  the  corpus  spongiosum  is  enlarged  and  forms 
the  bulb.  The  penis  at  its  root  is  firmly  connected  to  the  symphysis 
by  a  fibrous  band,  the  suspensory  ligament. 

The  three  cyclinders  which  together  form  the  penis  are  bound 
together  by  a  fibrous  sheath,  and  covered  with  a  soft,  loose,  movable 
envelope  of  skin,  which,  at  the  extremity,  is  reflected  over  the  glans 
for  a  greater  or  less  distance,  forming  the  prepuce.  The  constriction 
behind  the  glans  is  called  the  corona. 

Passing  forward  upon  the  dorsal  surface  of  the  penis,  in  the 
groove  between  the  corpora  cavernosa,  are  two  arteries,  one  on  each 
side,  the  dorsal  arteries  of  the  penis,  branches  of  the  internal  pudic, 
and  lying  between  the  two  arteries  is  the  single  dorsal  vein. 

The  urethral  canal,  from  the  internal  urethral  orifice  to  the 
external  meatus,  is  about  eight  inches  long.  It  is  described  as  con- 
sisting of  three  parts:  the  spong}^  the  membranous,  and  the  pros- 
tatic.    The  spong}'  portion  of  the  urethra  is  about  six  inches  long. 


678 


URINARY  SYSTEJkl. 


It  is  surrounded  for  its  whole  length  by  the  erectile  tissue  of  the 
corpus  spongiosum,  which  is  represented  behind  by  the  bulb  and 
anteriorly  by  the  glans.  The  membranous  portion  is  short — about 
three-fourths  inch  in  length — non-dilatable.  It  is  contained  between 
the  two  layers  of  the  triangular  ligament,  and  is  surrounded  in  this 
situation  by  the  fibers  of  the  compressor  urethrse  muscle.  The  pros- 
tatic portion  of  the  urethra  is  rather  more  than  one  inch  long  and 
is  very  room}"  (see  'page  694). 


OPERATIONS  UPON  THE  PENIS. 

Forcible  Dilatation  of  the  Prepuce  for  Phimosis. — This  may  be 
practiced  in  many  cases,  especially  in  newborn  and  young  children, 


Fig.  306.— Dorsal  Section  (Roser).  The  little  triangular  flap,  F,  is  turned 
back  and  sutured  to  the  corner  of  the  skin.  M,  edge  of  mucous  membrane; 
S,  edge  of  skin. 

instead  of  a  dorsal  section  or  circumcision.  An  anaesthetic  is  unnec- 
essary. The  skin  of  the  prepuce  is  seized  and  peeled  forcibly  back- 
ward over  the  glans  as  far  as  the  corona.  This  is  readily  done  in 
most  cases,  even  when  the  orifice  of  the  prepuce  is  quite  narrow. 
The  margin  of  the  prepuce  stretches  and  suffers  slight  tears  here 
and  there  about  its  circumference;  it  should  be  drawn  back  and 
forth  several  times,  and  again  repeated  daily  for  several  days.  When 
the  prepuce  is  drawn  back,  any  hardened  smegma  that  has  accumu- 
lated should  be  removed,  and  the  glans  washed  and  smeared  with 
oil  or  vaselin;  the  skin  is  then  again  drawn  forward  over  the  glans, 
since  the  constriction  of  the  narrow  prepuce  might  cause  some  incon- 
venience if  allowed  to  remain  back  behind  the  glans.  After  the  fore- 
skin has  been  drawn  back  and  forth  over  the  glans  a  dilator  may  be 
introduced  into  its  orifice,  and  it  may  then  be  forcibly  and  thoroughly 
dilated.  In  most  cases  this  is  unnecessary. 


OPERATIONS  UPON  THE  PENIS. 


679 


Dorsal  Section. — This  operation  is  done  for  phimosis  in  tlie 
young,  when  one  is  unable  to  retract  the  skin  and  when  it  is  not 
desirable  to  do  a  complete  circumcision,  and  in  adults  in  all  cases 
where  it  is  necessary  to  expose  the  glans  for  treatment. 

•The  skin  of  the  penis  is  rolled  slightly  back  toward  the  root  of 
the  organ  with  the  finger  and  thumb  and  one  blade  of  a  blunt- 
pointed  scissors  introduced  beneath  the  prepuce,  between  it  and  the 
glans,  as  far  back  as  the  corona,  and  the  foreskin  then  divided  along 
the  middle  line,  steadying  it  so  that  it  Avill  not  roll  or  slip.     The 


Fig.  307.— Circumcision.  Dorsal  section  has  been  made.  The  corners  of  the 
divided  prepuce  are  grasped  with  artery  forceps  and  the  prepuce  seized  with  a 
third  forceps  opposite  the  frsenum,  preparatory  to  trimming  it  away  with  the 
scissors.     The  dotted  line  represents  the  line  of  incision. 


scissors  should  be  sharp,  especially  toward  the  ends.  The  prepuce 
should  not  be  divided  for  its  whole  length,  but  only  to  within  a  short 
distance  of  the  corona. 

Care  should  be  exercised  not  to  introduce  the  blade  of  the  scissors 
into  the  urethral  canal  instead  of  between  the  glans  and  prepuce; 
this  might  happen  if  the  prepuce  Avere  intimately  adherent  to  the 
surface  of  the  glans,  as  is  sometimes  the  case. 

Instead  of  using  the  scissors  the  section  may  be  made  with  a 
sharp-pointed,  curved  bistoury,  guided  upon  a  grooved  director, 
which  is  introduced  underneath  the  prepuce,  between  it  and  the 
glans.    As  a  rule,  there  is  but  little  hemorrhage. 


G80  URIXAEY  SYSTEM. 

If  the  parts  are  not  infected,  one  or  two  catgut  stitches  may  be 
introduced  on  either  side.  Usuall}^  no  suture  is  necessarjr  in  the 
child. 

Eoser's  Method  of  Dorsal  Section. — After  tlie  dorsal  section 
has  been  made,  the  mucous  membrane  not  being  cut  as  far  back  as 
the  skin,  an  oblique  incision  is  made,  on  either  side,  from  the  corner 
•  of  the  mucous  membrane  backward  and  outward  as  far  as  the  edge  of 
the  skin.  The  little  triangular  mucous  membrane  flap  which  is  thus 
formed  is  then  turned  up  into  the  angle  in  the  skin,  to  insure  rapid 
healing  in  the  comer  of  the  incision ;  it  may  be  held  in  place  with  one 
stitch  in  the  angle  of  the  incision.  One  or  two  stitches  may  also  be 
introduced  on  either  side  of  the  incision  proper. 

Circumcision. — In  children  an  anaesthetic  is  necessary;  in  adults 
the  operation  may  be  done  under  the  influence  of  cocain,  which  is 
injected  into  the  prepuce  after  a  strip  of  gauze  has  been  tied  fairly 
tight  about  the  body  of  the  penis  near  its  root  to  prevent  diffusion 
of  the  cocain.  One  should  avoid  cutting  the  skin  too  short.  After 
the  parts  have  healed  there  should  be  a  little  redundancy  of  the  skin 
marking  the  previous  reflection  of  the  prepuce  and  this  is  best  ac- 
complished by  drawing  the  skin  a  little  backward,  toward  the  root 
of  the  penis,  before  applying  the  constricting  band.  The  first  step 
in  the  operation  is  the  dorsal  section  of  the  prepuce.  One  blade  of 
a  scissors  is  introduced  underneath  the  prepuce  to  a  point  just  an- 
terior to  the  corona  and  the  prepuce  is  then  divided  to  within  a  short 
distance  of  the  corona.  Either  corner  of  the  divided  prepuce  is  seized 
with  an  artery  clamp  close  to  the  edge  of  the  incision.  The  prepuce 
is  seized  with  a  third  clamp  which  is  placed  midway  between  the 
two  already  mentioned,  opposite  the  frsenum.  The  redundant  portion 
of  the  prepuce  is  trimmed  away  with  the  scissors.  The  entire 
length  of  the  prepuce  should  not  be  amputated;  about  one-fourth 
its  length  should  remain. 

As  a  rule,  the  bleeding  stops  when  the  ligature  around  the  penis 
is  removed  and  after  a  few  minutes'  compression.  All  bleeding 
should  be  checked  before  suturing,  if  necessar}^  applying  fine  catgut 
ligatures. 

The  edges  of  the  skin  and  mucous  membrane  are  united  with 
interrupted  plain  catgut  sutures,  the  first  being  applied  in  the  middle 
line  above,  the  next  in  the  middle  line  below,  then  one  on  each 
side,  and  finally  in  the  intervals  between  these,  making  eight  sutures 
In  all. 


OPERATIONS  UPON  THE  PENIS.  681 

In  tliG  c-liild,  as  a  rule,  the  foiir  sutures  are  sufficient. 

Circumcision  with  the  Clamp. — After  tlie  parts  have  been  anjes- 
thetizcd,  etc.,  the  etljjje  ol'  the  prepuce  is  seized  above  in  the  middle 
line  and  Ix'low  in  tlio  middle  lino  with  artery  forceps,  and  drawn 
forcibly  forward  over  the  glans.  That  part  of  the  prepuce  which 
is  thus  pulled  beyond  the  glans  is  grasped  between  the  blades  of  a 
long,  straiglit  clamp,  which  is  applied  obliquely  from  above  downward 
and  forward;  the  clamp  should  seize  the  foreskin  firmly  and  care 
should  be  observed  that  the  glans  is  not  included;  this  accident, 
however,  is  not  likely  to  occur. 

The  part  of  the  prepuce  which  protrudes  beyond  the  blades  of 
the  clamp  is  trimmed  off  with  a  sharp  Imife  or  with  the  scissors  plane 


Fig.  308. — Amputation  of  the  Penis.     CC,  corpora  cavernosa;  F,  skin  flap 
turned  back;  U,  urethral  portion  cut  long. 

with  the  surface  of  the  clamp,  and  the  clamp  then  removed.  The 
hemorrhage  is  controlled  and  the  sutures  applied  as  above. 

Amputation  of  the  Penis. — This  operation  is  done  for  malignant 
disease.  A  sound  is  passed  into  the  urethra,  and,  supported  upon 
this  the  penis  is  lifted  away  from  the  body.  An  elastic  ligature  is 
placed  about  the  organ  close  to  its  root. 

A  circular  incision  is  made  through  the  integument  and  a  flap 
reflected  sufficiently  long  to  cover  over  the  stump  of  the  penis;  it 
should  be  equal  in  length  to  half  the  diameter  of  the  penis  plus  one- 
third  for  shrinkage.  After  the  flap  has  been  turned  back  like  a  cuff 
the  portion  of  the  penis  that  is  to  be  amputated  is  cut  away.  The 
urethral  portion  of  the  penis  should  be  cut  about  one-fourth  inch 
longer   than    the    part    that    corresponds   to    the   corpora    cavernosa. 

The  blade  of  the  scalpel  is  thrust  flatwise  through  the  penis 
between  the  urethral  portion,  which  may  be  recognized  by  the  sound 
within,  and  the  corpora  cavernosa,  and  carried  a  good  one-fourth 
inch  forward   toward   the   glans,   when   the  urethral   portion  is   cut 


682  URINARY  SYSTEM. 

through  with  a  circular  sweep  of  the  knife  down  upon  the  sound 
contained  within.  The  corpora  cavernosa  are  then  divided  upon  a 
plane  farther  hack,  corresponding  to  the  base  of  the  skin  j&ap,  so  that 
the  urethral  portion  will  project  about  on£-fourth  inch  beyond  the 
cut  surface  of  the  corpora  cavernosa. 

The  tourniquet  is  now  removed  from  the  root  of  the  penis.  The 
dorsal  arteries  bleed,  and  require  to  be  clamped  and  ligated.  The 
arteries  of  the  corpora  cavernosa  usually  require  no  ligatures ;  if  they 
spurt,  they  may  be  clamped  or  touched  with  the  Paquelin.  A  few 
minutes^  compression  usually  sufficies  to  check  bleeding  from  any 
remaining  sources. 

The  edges  of  the  urethra  are  seized  with  two  artery  clamps  and 
the  urethra  is  then  split  upon  its  under  aspect  for  a  distance  of  about 


Fig.  309. — Amputation  of  the  Penis.  Edges  of  skin  flap  united  to  each 
other  over  the  ends  of  the  corpora  cavernosa  and  to  the  edges  of  the  split 
urethral  portion. 

one-fourth  inch.  The  skin  flaps  are  turned  over  the  end  of  the 
stump  and  are  united  from  before  backward  with  several  inter- 
rupted sutures  and  the  edges  of  the  split  urethral  orifice  are  sewed 
to  the  adjoining  edges  of  the  skin  -flaps. 

The  object  of  cutting  the  urethra  long  and  splitting  it  is  to 
provide  a  larger  orifice  to  allow  for  subsequent  contraction. 

A  soft  rubber,  self-retaining  catheter  is  introduced  into  the 
bladder  and  allowed  to  remain  for  several  days. 

THE  PERINEUM  AND  ISCHIO=RECTAL  REGION. 

The  Floor  of  the  Pelvis  from  Without  Inward. — This  space  is 
lozenge-shaped;  its  front  portion  is  limited  on  either  side  by  the 
rami  of  the  pubes  and  ischium ;  its  posterior  part  is  limited  on  either 
side  by  the  edges  of  the  great  sacro-sciatic  ligaments.  The  anterior 
angle  corresponds  to  the  symphysis  pubis,  the  posterior  angle  to  the 
tip  of  the  coccyx,  and  on  either  side  the  tuber  ischii  may  be  felt. 


PERINEUM  AND  ISCHIORECTAL  REGION.  G83 

Tlicre  is  a  more  or  less  complete  fibrous  raphe  running  from  before 
backward  in  the  middle  line,  and  also  one  from  side  to  side  where 
all  the  layers  of  the  perineal  fascia  are  blended  together.  Where  these 
lines  intersect  there  is  a  point  where  muscles  are  attached  and  take 
origin  and  where  all  the  fasciae  are  joined.  This  is  known  as  the  cen- 
tral tendinous  point  of  the  perineum.  The  space  in  front  of  the  trans- 
verse raphe  is  the  perineum  proper;  the  space  behind  it  is  occupied 
by  the  anus  and  upon  either  side  by  the  ischio-rectal  fossa,  and  is 
Icnown  as  the  ischio-rectal  region. 

The  Superficial  I^vyer  of  the  SurERFiciAL  Periisteal 
Fascia. — Beneath  the  skin  there  is  a  layer  of  loose  fascia  which  is 
continuous  with  the  superficial  fascia  of  the  thighs  and  buttocks. 
This  is  the  superficial  layer  of  the  superficial  fascia  of  the  perineum 
and  ischio-rectal  regions;  it  corresponds  to  the  subcutaneous  fat,  and 
is  continuous  in  front  with  the  dartos  layer  of  the  scrotum,  and 
behiud,  upon  either  side  of  the  anus,  it  is  packed  into  the  ischio-rectal 
fossa  as  a  pyramidal  plug  of  fat  and  loose  connective  tissue. 

The  Deep  Layer  of  Superficial  Perineal  Fascia. — If  we 
remove  the  superficial  layer  of  fascia  and  fat,  including  the  mass 
from  the  ischio-rectal  fossa,  we  come  down  upon  a  second  layer  of 
fascia,  the  deep  layer  of  the  superficial  fascia  of  the  perineum.  Cor- 
responding to  the  perineal  region  proper,  the  fascia  is  attached  upon 
each  side  to  the  edge  of  the  pubic  arch  and  behind  to  the  transverse 
raphe;  in  front  it  is  continuous  with  the  dartos  of  the  scrotum; 
behind,  in  the  ischio-rectal  region,  it  is  continuous  with  the  anal 
fascia,  which  covers  the  perineal  surface  of  the  levator  ani  muscles. 

Anteriorly  this  fascia  is  dense,  and  serves  to  close  in  the  struct- 
ures proper  to  the  perineum.  If  fluid  is  injected  underneath  this 
layer  of  fascia,  it  will  not  spread  backward  beyond  the  transverse 
raphe,  because  this  layer  of  fascia  is  attached  along  this  raphe  with 
the  next  underlying  fascial  layer;  it  will  not  escape  laterally,  owing 
to  the  attachment  of  the  fascia  to  the  margins  of  the  bony  pelvic 
arch;  but  anteriorly  it  will  escape,  passing  into  the  dartos  tissue  of 
the  scrotum  and  thence  upward  upon  the  front  of  the  pubes. 

The  Ischio-rectal  Region. — This  is  the  region  which  lies  behind 
the  transverse  raphe — that  part  which  corresponds  to  the  anus  and 
the  ischio-rectal  fossa. 

In  the  middle  is  the  anus,  surrounded  by  its  external  sphincter 
muscle.  This  muscle  arises  from  the  tip  of  the  coccyx  behind,  and, 
passing  forward,  is  attached,  in  front  of  the  anus,   to  the  middle 


(3S4:  URINARY  SYSTEM. 

tendinous  point  of  the  perineum^  which  corresponds  to  the  junction 
of  the  sphincter  from  behind,  tlie  transversus  perinei  from  each  side, 
and  the  bulbo-cavernosus  from  in  front. 

On  either  side  of  the  anus  there  is  a  pyramidal  space,  the  ischio- 
rectal fossa;  this  space  is  occupied  by  a  mass  of  fat  and  loose  con- 
nective tissue,  the  base  of  which  corresponds  to  the  superficial  layer 
of  superficial  perineal  fascia,  and  reaches  from  the  tuberosity  of  the 
ischium  to  the  anus.  This  space  is  about  two  inches  deep.  Its  outer 
wall  is  formed  by  the  tuber  ischii  and  the  obturator  internus  muscle, 
which  muscle  is  covered  over  by  a  layer  of  fascia,  the  obturator  fascia. 
Passing  forward  upon  this  outer  wall  of  the  ischio-rectal  fossa,  be- 
neath the  obturator  fascia  and  about  one  and  one-half  inches  above 
the  tuberosity  of  the  ischium,  are  the  internal  pudic  vessels  and 
nerve.  The  inner  wall  of  the  ischio-rectal  space  is  formed  by  the 
levator  ani  (to  be  described  later).  The  superficial  surface  of  this 
muscle,  which  looks  into  the  ischio-rectal  space,  is  covered  by  the 
anal  fascia,  which  is  derived  from  the  obturator  fascia  along  the  line 
of  origin  of  the  levator  ani  from  the  side  of  the  pelvis.  This 
anal  fascia  is  attached  in  front  to  the  transverse  fibrous  raphe  and  is 
continuous  there  with  the  deep  layer  of  the  superficial  perineal  fascia. 

The  ischio-rectal  space  is  thus  walled  off  from  the  perineal  space 
proper  and  from  the  rectum.  It  is  the  seat  of  the  so-called  ischio- 
rectal abscess,  and  when  this  breaks  through  into  the  rectum  it  forms 
the  fistula  in  ano. 

Some  small  vessels  and  nerve  branches  cross  this  space  trans- 
versely just  beneath  the  skin,  passing  from  the  tuberosity  of  the 
ischium  toward  the  anus,  and  these  are  cut  when  incisions  are  made 
into  the  space. 

The  Perineum. — ^Upon  removing  the  deep  layer  of  superficial 
perineal  fascia  we  open  into  the  proper  perineal  space. 

Occupying  the  middle  of  the  space  is  a  thin  muscle,  the  bulbo- 
cavernosus;  it  arises  from  the  middle  tendinous  point  of  the 
perineum,  and,  passing  forward,  covers  the  bulb  of  the  urethra, 
which  is  the  posterior  enlarged  portion  of  the  corpus  spongiosum, 
joining,  with  fibers  from  the  muscle  of  the  opposite  side  upon  its 
upper  surface,  in  a  strong  aponeurosis.  The  most  anterior  fibers  of 
the  bulbo-cavernosus  muscle  are  attached  on  either  side  to  the  crus 
penis,  some  entirely  encircling  these  bodies  and  joining  upon  the 
upper  s^urface  of  the  root  of  the  penis,  in  such  a  way  as  to  bind 
down  the   dorsal   vessels   of  the   penis,   obstructing  the   return   flow 


PERINEUM  AND  ISCHIORECTAL  REGION. 


G85 


through  tlie  vein.  This  muscle  shows  a  median  fibrous  raplie.  Upon 
either  side,  arising  fi-om  the  ascending  ramus  of  the  ischium,  is  the 
ischio-cavernosus.  Tlie  llbei's  of  tliis  muscle  partly  cover  the  crus 
penis  and  are  attached  to  its  sheath.  Tlie  crus  penis  is  the  posterior 
portion  of  the  corpus  cavernosum  and  is  attached  to  the  ramus  of 
the  ischium  and  pubes. 


Fig.  310. — The  Perineum  and  Ischio-rectal  Region.  The  superficial  and  deep 
layers  of  the  superficial  perineal  fascia  have  been  removed.  The  space  in  front 
of  the  transversus  perinei  (TP)  corresponds  to  the  perineum;  that  behind  the 
transversus  perinei  to  the  ischio-rectal  region.  The  floor  of  the  space  (TL) 
corresponds  to  the  anterior  layer  of  the  triangular  ligament.  BG,  bulbo-cavern- 
osus  muscle;  C,  tip  of  coccyx;  CC,  corpus  cavernosum  (crus  penis);  C8,  corpus 
spongiosum  (the  posterior  part  of  the  corpus  spongiosum  is  called  the  bulb 
of  the  urethra);  G,  edge  of  gluteus  maximus  muscle;  IG,  ischio-cavernosus 
muscle;  LA,  levator  ani  muscle;  R,  ramus  of  the  pubes  and  ischium;  SA, 
sphincter  ani;  8L,  edge  of  great  sacro-sciatic  ligament;  TI,  tuberosity  of  the 
Ischium;  TL,  superficial  or  anterior  layer  of  the  triangular  ligament;  TP,  trans- 
versus perinei  muscle. 


Forming  the  posterior  border  of  this  space  on  either  side  is  the 
transversus  perinei  muscle.  This  muscle  arises  from  the  inner  surface 
of  the  tuberosity  of  the  ischium ;  it  passes  inward  and  forward  to  the 
central  tendinous  point  of  the  perineum,  where  it  is  attached,  joining 
with  the  muscle  of  the  opposite  side  and  the  other  muscles  already 
described. 

Passing  forward  through  this  space  are  the  superficial  perineal 


686  URINARY  SYSTEM. 

vessels  and  nerve,  and  directed  inward  along  the  border  of  the 
transversus  perinei  is  the  transverse  perineal  artery. 

The  floor  of  this  space  is  formed  hy  a  dense  layer  of  fascia,  the 
superj&cial  layer  of  the  deep  perineal  fascia,  or,  better,  of  the  triangular 
ligament.  This  la5^er  of  fascia  is  perforated  by  the  urethral  canal 
about  one  and  one-half  inches  below  the  S5anphysis.  Beneath  this 
layer  of  fascia  there  is  a  second  layer,  similar  in  structure,  the  deep 
layer  of  the  deep  perineal  fascia  or  triangular  ligament. 

Behind,  corresponding  to  the  transverse  perineal  raphe,  these 
two  layers  of  deep  fascia  are  blended  with  each  other  and  with  the 
deep  la5'er  of  the  superficial  perineal  fascia.  They  are  attached  later- 
ally to  the  inner  surface  of  the  rami  of  the  pubes  and  ischium ;  above, 
in  front,  they  do  not  reach  to  the  sjmiphysis,  but  terminate  in  the 
ligamentum  transversum  pelvis,  a  ligamentous  band  passing  between 
both  pubic  rami,  leaving  a  space  above,  between  it  and  the  symphysis, 
for  the  passage  of  the  vena  dorsalis  penis. 

Between  the  two  layers  of  the  triangular  ligament  the  deep 
transverse  perineal  muscle,  the  compressor  urethra,  is  located;  this 
muscle  is  made  up  chiefly  of  striped  muscular  fibers  passing  across 
from  one  pubic  ramus  to  the  other  above  and  below  the  urethra,  and 
also  of  unstriped  fibers  which  pass  in  various  directions,  some 
encircling  the  membranous  part  of  the  urethra. 

The  two  layers  of  the  triangular  ligament,  together  with  the 
muscle  contained  between  them,  form  the  uro-genital  diaphragm.  In 
the  space  between  the  two  layers  of  the  triangular  ligament,  besides 
the  muscle,  are  contained  the  urethra,  its  membranous  portion,  and 
behind,  on  either  side,  Cowper's  gland,  the  duct  of  which  is  seen 
passing  forward  to  enter  the  bulbous  portion  of  the  urethra.  Poste- 
riorly, close  to  the  lateral  border  of  the  space,  is  seen  the  internal 
pudie  artery.  It  gives  off  the  artery  of  the  bulb,  and  passing  forward 
divides  into  the  artery  of  the  crus  penis,  which  enters  the  cms,  and 
the  dorsal  artery  of  the  penis,  which  perforates  the  suspensory  liga- 
ment and  runs  forw'ard  along  the  upper  surface  of  the  penis. 

As  the  urethra  perforates  the  superficial  layer  of  the  triangular 
ligament  it  is  provided  with  a  fibrous  prolongation,  which  is  con- 
tinued forward  upon  the  bulb  of  the  urethra. 

The  posterior  or  deep  layer  of  the  triangular  ligament  is  really 
the  very  much  thickened  portion  of  the  pelvic  fascia  which  fills  in 
the  space  between  the  two  levatores  ani  muscles.  The  levatores  ani 
muscles  form  the  major  part  of  the  floor  of  the  pelvis. 


PERINEUM  AND  ISCHIO-RECTAL  REGION.  687 

The  prostate  gland,  which  encircles  the  neck  of  the  bladder  and 
contains  the  prostatic  portion  of  the  urethra,  is  situated  in  the 
pelvic  cavity.  It  rests  upon  the  upper,  pelvic  surface  of  tlie  triangular 
ligament'  and  levatores  ani  muscles. 

The  vesiculae  seminales  and  the  vasa  deferentia  lie  within  the 
pelvis,  between  the  rectum  and  the  base  or  trigone  of  the  bladder, 
above  the  base  of  the  prostate.  They  may  be  brought  into  view  by 
separating  the  rectum  from  the  base  of  the  bladder  and  drawing  it,  the 
rectum,  backn^ard  toward  the  coccyx. 

The  Pelvic  Cavity  from  Within. — Examining  the  pelvic  cavity 
from  within,  after  removal  of  the  bladder  and  rectum,_we  find  it 
bounded  in  front  by  the  pubic  bones,  behind  by  the  coccyx  and 
sacrum,  laterally  by  the  pubes  and  ischium  and  the  sacro-sciatic 
ligaments.  The  lateral  wall  of  the  pelvic  cavity  is  partly  covered  by 
the  obturator  internus  muscle,  which  arises  from  the  inner  surface 
of  the  pubes  and  ischium  around  the  margin  of  the  obturator  foramen. 
The  obturator  internus  is  covered  by  a  thick  fascia,  which  is  attached 
above  to  the  margin  of  the  brim  of  the  pelvis,  being  continuous 
above  with  the  fascia  that  covers  the  psoas  and  iliacus  muscles  (the 
fascia  iliaca). 

The  Levatores  Axi  form  the  major  part  of  the  floor  of  the 
pelvis.  The  fascia  that  covers  the  obturator  internus  is  marked  by 
a  thick,  white,  fibrous  band  which  extends  along  the  lateral  wall  of 
the  pelvis,  from  before  backward,  from  the  posterior  surface  of  the 
pubic  bone  in  front,  to  the  spine  of  the  ischium,  behind.  This  line 
is  called  the  "white  line"  or  the  tendo  arcuatum.  The  levatores  ani 
arise  from  the  posterior  surface  of  the  pubic  bones  and  from  the 
whole  length  of  the  "white  line"  upon  either  lateral  wall  of  the  pelvis. 
The  muscles  pass  in  a  general  direction  obliquely  downward,  back- 
ward and  inward.  Anteriorly  a  wide  space  intervenes  between  the 
inner  edges  of  the  two  muscles.  More  posteriorly  they  pass  under- 
neath the  prostate,  which  they  support  in  a  sling-like  manner.  Still 
morr^  posteriorly  they  grip  the  rectum  between  them,  some  of  the  fibers 
beink-  inserted  into  the  rectal  wall.  Behind  the  rectum  the  fibers  of 
both  muscles  join  together  in  the  middle  line  to  close  in  this  part 
of  the  pelvic  floor,  and  are  then  finally  attached  to  the  tip  and  sides 
of  the  coccyx.  Anteriorly  the  space  between  the  edges  of  the  two 
muscles  is  filled  in  by  a  dense  fascia — the  posterior  or  deep  layer 
of  the  deep  perineal  fascia  or,  as  it  is  sometimes  called,  the  triangular 
ligament.    This  fascia  is  also  called  the  trigonum  uro-genitale. 


688  URINARY  SYSTEM. 

The  back  part  of  the  floor  of  the  pelvis,  posterior  to  the  levatores 
ani,  is  formed  by  the  coccygeus  muscles.  Tliese  muscles  look  like  a 
continuation  of  the  levatores  ani  and  serve  to  close  in  the  back  part 
of  the  outlet  of  the  pelvis.  The  muscles  are  fan-shaped  and  are 
attached  by  their  apices  to  the  spines  of  the  ischium  and  by  their 
broad  bases  to  the  lateral  margins  of  the  coccyx. 

Lying  upon  the  same  plane,  but  still  farther  above  and  behind, ' 
and  corresponding  to  the  upper  border  of  the  coccygeus  muscle,  is 
the  pyriformis.  This  muscle  arises  from  the  sides  and  from  the  ante- 
rior surface  of  the  sacrum,  and  passing  outward  leaves  the  pelvis 
through  the  great  sacro-sciatic  notch,  and  closes  the  pelvic  cavity 
behind. 

Thus,  taking  part  in  the  formation  of  the  floor  of  the  pelvis, 
there  is  a  muscular  layer  which  is  formed  in  front  and  upon  the  sides 
by  the  levatores  ani,  behind  this  by  the  coccygei,  and  still  farther 
behind  and  above  by  the  pyriformi. 

The  fascia  that  fills  in  the  space  anteriorly  between  the  edges 
of  the  levatores  ani,  the  posterior  or  deep  laj^er  of  the  triangular 
ligament,  is  perforated  in  the  male  by  the  urethra,  in  the  female 
by  the  urethra  and  vagina. 

The  Pelvic  Fascia  covers  the  obturator  internus  muscle  and, 
corresponding  to  the  "white  line,"  iendo  arcuatum,  which  marks  the 
origin  of  the  levator  ani,  is  continued  upon  the  upper,  pelvic  surface 
of  the  levator  ani.  It  bridges  across  the  space  which  exists  between 
the  levator  muscles  anteriorly,  and  forms  the  deep  layer  of.  the 
triangular  ligament  (already  mentioned,  and  which  is  perforated 
by  the  urethra  in  the  male  and  the  urethra  and  vagina  in  the  female). 
In  the  back  part  of  the  pelvic  cavity  this  same  fascia  covers  over  the 
surface  of  the  coccygeus  and  the  pyriformis  muscles.  Thus  the  entire 
interior  of  the  pelvic  cavity  is  lined  by  the  pelvic  fascia  in  a  manner 
similar  to  that  in  which  the  interior  of  the  abdominal  cavity  is  lined 
by  the  transversalis  fascia. 

Where  the  pelvic  fascia,  after  covering  the  pelvic  surface  of  the 
levatores,  strikes  the  prostate  gland  and  the  rectum  and  the  vagina 
in  the  female,  it  is  reflected  upward  upon  the  sides  of  these  organs, 
and  serves  to  materially  strengthen  them.  It  is  gradually  lost  in  the 
wall  of  the  rectum  and  vagina.  It  forms  a  strong,  fibrous  sheath  for 
the  prostate  gland.  Above  the  base  of  the  prostate  the  fascia  is  con- 
tinued on  to  the  wall  of  the  bladder.  It  gradually  thins  out  and  is 
lost  on  the  wall  of  the  bladder. 


OPERATIONS  UPON  THE  PERINEUM,  ETC.  •  GsP 

A  process  of  the  pelvic  fascia  is  reflected  inward  l)et\veen  the 
rectum  and  the  l)ase  of  the  bladder,  and  serves  to  bind  the  seminal 
vesicles  and  the  vasa  deferentia  to  the  base  of  the  bladder. 

The  under  surface  of  the  levator  ani,  which  is  directed  toward 
the  pcriiieum  and  ischio-rectal  fossa,  is  also  covered  by  a  thin  layer 
of  fascia  which  is  derived  from  the  obturator  fascia  along  the  line  of 
origin  of  the  levator  ani.  This  is  called  the  anal  fascia.  The  anal 
fascia  is  continued  backward  upon  the  under  surface  of  the  coccygeus 
muscle,  and  anteriorly  is  continued  forward  into  the  deep  layer  of 
the  superficial  perineal  fascia,  joining  along  the  transverse  septum, 
or  raphe,  with  all  the  other  fasciae  of  the  perineum. 

OPERATIONS  UPON  THE  PERINEUM,   ETC. 

Perineal  Section  (External  Urethrotomy)  With  a  Guide. — ^This 
operation  is  performed  for  stricture  of  the  deep  urethra  or  for  the 
purpose  of  draining  the  bladder.  The  patient  is  placed  in  the 
lithotomy  position  and  a  tunneled  sound  introduced  through  the 
urethra  into  the  bladder. 

An  assistant  steadies  the  sound  with  the  right  hand,  throwing 
the  groove  as  much  as  possible  toward  the  surface  of  the  perineum, 
and  at  the  same  time  drawing  the  whole  urethra  upward,  away  from 
the  rectum  toward  the  symphysis.  The  scrotum  is  drawn  up  toward 
the  s}Tnphysis,  out  of  the  way  of  the  operator. 

An  incision  is  made  in  the  middle  line  from  the  base  of  the 
scrotum  backward  to  within  a  short  distance  of  the  anus.  This  in- 
cision reaches  through  the  skin  and  fat  down  to  the  deep  layer  of 
the  superificial  perineal  fascia. 

The  edges  of  the  wound  are  drawn  asunder  with  small,  sharp 
retractors,  and  with  another  stroke  of  the  knife  the  deep  layer  of 
the  superficial  perineal  fascia  is  incised  and  the  bulb  of  the  urethra 
exposed  in  the  forward  part  of  the  wound.  Then,  with  the  finger 
in  the  wound,  the  groove  in  the  tunneled  guide  within  the  urethra 
is  recognized  and  the  point  of  the  knife,  guided  upon  the  finger-nail, 
is  placed  in  the  gi'oove  of  the  sound,  piercing  the  membranous  part 
of  the  urethra  just  behind  the  bulb.  The  knife  is  then  shoved  back- 
ward, carrying  the  point  of  the  blade  along  the  groove  of  the  sound 
toward  the  neck  of  the  bladder  and  raising  the  handle,  at  the  same 
time,  toward  the  symphysis.  Having  carried  the  point  of  the  knife 
'beyond  the  location  of  the  stricture,  into  the  prostatic  portion  of  the 
urethra,  the  handle  is  depressed,  the  knife  at  the  same  time  being 


690  '  URI^^AEY  SYSTEM. 

withdra^^Ti  and  cutting  as  it  is  withdrawn;  in  this  way  the  mem- 
branous portion  of  the  urethra  is  laid  open  and  the  stricture  divided. 

While  the  urethra  is  being  incised  upon  the  grooved  sound  the 
sound  should  be  lifted  straight  up  toward  the  symphysis,  carrying 
the  urethra  with  it^,  and  thus  drawing  it  farther  away  from  the 
rectum.  If  some  urine  or  fluid  is  in  the  bladder,  its  escape  will 
demonstrate  the  fact  that  the  bladder  has  been  entered. 

A  director  gorget  may  now  be  introduced  into  the  bladder  along 
the  groove  of  the  sound  and  the  latter  withdrawn.  A  soft  rubber 
catheter  of  large  caliber  is  introduced  through  the  opening  into  the 
bladder,  and  fixed  in  place  to  the  edge  of  the  incision  in  the  skin 
with  a  silk  stitch,  and  the  wound  then  packed  about  the  catheter 
with  strip  gauze  to  control  hemorrhage. 

Usually  there  are  no  vessels  to  tie,  although  spurting  arterial 
branches  should  be  clamped  and  twisted  and,  if  necessary,  ligated. 
One  should  avoid  wounding  the  bulb  of  the  urethra  if  possible,  and, 
for  a  certainty,  the  rectum  and  anus. 

Before  dismissing  the  patient,  a  large  metal  sound,  at  least  a 
ISTo.  30  F.,  should  be  passed  through  the  anterior  urethra  and  into 
the  bladder  to  make  certain  that  no  remaining  obstruction  exists  in 
any  part  of  the  canal. 

Perineal  Section  Without  a  Guide. — This  is  a  difficult  procedure. 

All  attempts  to  introduce  a  guide  through  the  constricted  part 
of  the  urethra  into  the  bladder  fail.  One  should  not  be  satisfied  with 
a  single  attempt,  but  should  try,  if  possible,  to  at  least  get  a  small 
whalebone  or  rubber  guide  through.  After  having  made  the  attempt 
and  found  it  imj)ossible  to  get  any  guide  whatever  past  the  stricture, 
a  tunneled  sound  may  be  introduced  as  far  as  the  obstruction. 

As  described  in  the  preceding  operation,  an  incision  is  made  in 
the  perineum  and  the  urethral  canal  opened  upon  the  guide  just  in 
front  of  the  stricture.  After  all  the  bleeding  has  been  arrested,  the 
edges  of  the  wound,  including  the  edges  of  the  incised  urethra,  are 
retracted  with  small,  sharp  hooks,  and  an  efi:ort  then  made  to  find 
the  opening  through  the  stricture  into  the  posterior  part  of  the  ure- 
thra by  inspection  or  by  attempting  to  pass  a  fine  probe-pointed 
director  or  a  fine  whalebone  g'aide. 

If  we  do  not  succeed  in  getting  through  the  stricture  by  these 
means  an  effort  may  be  made  to  open  into  the  urethra  behind  the 
stricture,  and  then,  if  this  is  successful,  the  stricture  may  be  divided 
from  behind.     It  is   difficult,   however,   to   locate   the   deep   urethra 


OPERATIONS  UPON  THE  PERINEUM,  ETC.  691 

(membranous  portion)  without  a  guide.  It  lies  between  tlie  layers 
of  the  triangular  ligament,  reaching  from  the  bulbous  portion  of  the 
urethra  to  the  apex  of  the  prostate  gland.  Occasionally  the  urethra 
is  diverted  from  the  middle  line  or  a  false  passage  may  be  encountered 
which  will  still  further  confuse  us. 

At  times,  especially  if  the  bladder  contains  fluid  and  pressure  be 
made  above  the  pubes,  the  urethra  may  be  felt  as  a  rounded,  com- 
pressible tube,  occupying  the  middle  line  and  perforating  the  tri- 
angular ligament  about  one  and  one-half  inches  below  the  symphysis. 

The  prostatic  urethra,  Avhieh  is  the  continuation  of  the  mem- 
branous urethra,  is  surrounded  by  the  prostate  gland,  and,  if  one 
finger  is  introduced  into  the  rectum  and  the  thumb  placed  in  the 
incision  in  the  perineum  the  operator  may  get  the  prostate  between 
them,  and  the  apex  of  the  prostate  may  thus  sen^e  as  a  clue  to  the 
location  of  the  membranous  urethra.  One  should  refrain  from  blindly 
jabbing  in  the  wound  in  the  hope  of  accidentally  striking  the  urethra. 

If  all  these  measures  fail,  a  suprapul:)ic  cystotomy  may  be  per- 
formed and  a  guide  passed  from  within  the  bladder  into  the  urethral 
canal,  in  this  way  locating  the  posterior  part  of  the  deep  urethra  for 
the  purpose  of  incision. 

If  it  becomes  necessary  to  do  a  suprapubic  cystotomy,  this  may 
be  more  conveniently  done  with  the  patient  in  the  Trendelenburg 
position. 

Median  Lithotomy. — ^This  operation  is  performed  for  small  calculi. 
The  bladder  should  be  washed  out  with  boric-acid  solution,  5  or  6 
ounces  being  allowed  to  remain  in  the  bladder.  The  operation  is 
practically  the  same  as  the  preceding  perineal  section  (with  a  guide) 
except  that  the  incision  into  the  urethra  is  made  rather  more  ex- 
tensive, cutting  through  the  anterior  part  of  the  prostatic  as  well  as 
through  the  membranous  portion  of  the  urethra.  The  incision  should 
not  extend  entirely  through  the  prostate.  Oftentimes  after  the  blad- 
der has  been  opened  a  small  stone  will  of  itself  drop  out  of  the 
wound,  or  it  can  be  removed  with  forceps,  scoop,  etc.  It  may  be 
necessary  to  enlarge  the  internal  urethral  orifice  somewhat  with  a 
dilator  or  with  the  finger.  If  necessary,  a  large  stone  may  be 
crushed  before  removal. 

The  finger  should  be  introduced  into  the  bladder  to  search  for 
partially  encysted  stones,  etc.  Finally  the  bladder  is  washed  out  and 
a  large,  rubber  catheter  introduced  through  the  perineal  wound  and 


692  URINARY  SYSTEM. 

fixed  to  the  edge  of  the  skin  with  a  silk  stitch.  The  wound  is  packed 
about  the  catheter  and  left  open. 

Lateral  Lithotomy. — The  bladder  is  washed  out  with  boric-acid 
solution^  4  or  5  ounces  being  left  remaining  in  the  bladder.  A  tun- 
neled sound  is  introduced  through  the  urethra  into  the  bladder  and 
steadied  by  an  assistant.  An  incision  is  made  through  the  skin  and 
fat,  commencing  in  front  at  the  base  of  the  scrotum  and  passing  back- 
ward and  outward  to  a  point  midway  between  the  tuberosity  of  the 
ischium  and  the  anus.  A  second  sweep  of  the  knife  incises  the  deep 
layer  of  the  superficial  perineal  fascia.  The  index  finger  of  the  left 
hand  is  then  introduced  into  the  wound,  and  the  finger-nail  placed  in 
the  groove  of  the  sound  in  the  front  part  of  the  wound,  just  behind 
the  bulb  of  the  urethra.  The  sound  is  then  drawn  upward  toward  the 
symphysis,  thus  lifting  the  whole  urethra  away  from  the  rectum,  and 
the  point  of  the  knife  placed  in  the  groove  of  the  sound,  cutting 
through  the  membranous  urethra.  The  handle  of  the  knife  is  then 
elevated  and  the  point  shoved  backward  along  the  groove  of  the  guide 
into  the  prostatic  urethra.  The  handle  of  the  knife  is  then  depressed, 
at  the  same  time  withdrawing  the  blade  and  cutting  as  it  is  with- 
drawn. In  this  way  the  membranous  urethra  and  the  side  of  the  pros- 
tate itself,  are  incised,  the  division  of  these  deep  structures  being  made 
along  the  line  of  the  skin  incision. 

In  making  this  last  incision  upon  the  sound  the  superficial  trans- 
verse perineal  miiscle,  and  the  artery  of  the  bulb,  together  with  the 
membranous  urethra,  the  prostate  gland,  and  the  triangular  ligament 
are  cut.  It  is  usually  necessary  to  clamp  and  tie  the  artery  of  the 
bulb,  and  sometimes,  if  the  incision  extends  too  far  backward  and 
outward,  the  internal  pudic  may  be  divided;  this  branch  bleeds  pro- 
fusely, and  must  be  tied.  After  the  bleeding  has  been  controlled  and 
the  stone  removed,  a  catheter  is  introduced  into  the  bladder  and  fixed 
to  the  edge  of  the  incision.  The  wound  is  packed  about  the  catheter 
and  left  un sutured. 

The  perineal  operations  are  rarely  performed  at  the  present  time 
for  the  removal  of  the  stone  from  the  bladder.  The  suprapubic 
operation  offers  a  much  more  satisfactory  route. 

THE  PROSTATE. 

Surreal  Anatomy  of  the  Prostate. — The  prostate  is  a  glandular 
organ  about  the  size  and  shape  of  a  horse-chestnut.  It  is  lodged  in 
the  pelvic  cavity  behind  and  below  the  symphysis.     It  surrounds  the 


SURGICAL  ANATOMY  OF  THE  PROSTATE.  G93 

neck  of  the  bladder  and  prostatic  portion  of  the  urethra.  The 
prostate  is  situated  deep  in  the  pelvic  cavity,  beneath  the  deep 
perineal  fascia  (triangular  ligament),  above  the  level  of  the  leva- 
tores  ani  muscles.  It  is  partly  supported  by  the  edges  of  the  levatores 
and  rests  with  its  apex  upon  the  upper  surface  of  the  deep,  posterior, 
layer  of  the  deep  perineal  fascia.  The  posterior  surface  of  the  pros- 
tate rests  against  the  lower  part  of  the  upper  portion  of  the  rectum, 
above  the  anal  portion.  The  gland  may  be  readily  palpated  with  the 
finger  in  the  rectum,  especially  if  it  is  enlarged. 

The  prostate  measures  about  one  and  one-half  inches  in  its  trans- 
verse and  one  inch  in  its  antero-posterior  diameter  at  the  base  and 
is  three-fourths  of  an  inch  in  depth.  It  is  held  in  position  by  the 
anterior  ligaments  of  the  bladder  (pubo-prostatic)  and  by  the  poste- 
rior layer  of  the  deep  perineal  fascia  (triangular  ligament),  which  is 
reflected  upward  and  backward  around  the  gland  forming  its  external 
fibrous  sheath.  The  prostate  rests  upon  the  anterior  portions  of  the 
levatores  ani,  which  pass  downward,  backward  and  inward  from  their 
origin  upon  either  side  of  the  internal  aspect  of  the  symphysis  pubis 
and  sides  of  the  pelvis,  some  of  their  fibers  being  attached  to  the 
sides  of  the  prostate  and  others  joining  with  their  fellows  in  the 
middle  line,  sling-like,  imderneath  the  prostate.  Those  portions  of 
the  levatores  ani  that  pass  underneath  and  support  the  prostate  are 
sometimes  called  the  levatores  prostatas. 

The  base  of  the  prostate  is  directed  upward  and  backward  toward 
the  neck  of  the  bladder.  The  narrow  end,  apex,  is  directed  forward 
and  downward  toward  the  deep  perineal  fascia.  The  posterior  sur- 
face rests  against  the  lower  part  of  the  upper,  ampulla  portion  of  the 
the  rectum — just  above  the  anal  portion.  This  surface  is  marked 
above,  at  the  base,  by  a  deep  notch,  the  interlobular  notch,  w'here 
the  ejaculatory  ducts  enter.  The  anterior  surface  is  marked  by  a 
slight  longitudinal  furrow,  is  notched  above  and  below,  and  lies  about 
one  inch  distant  from  the  symphysis  pubis. 

The  prostate  is  composed  of  glandular  and  unstriped  muscular 
tissue.  It  is  enclosed  within  its  own  proper  capsule  and  is  made  up 
of  two  lateral  lobes  and  a  middle  portion  or,  as  it  is  sometimes  called, 
a  '^middle  lobe."  The  two  lateral  lobes  are  symmetrical  and  separated 
behind,  at  the  base,  by  the  interlobular  notch,  at  which  point  the 
ejaculatory  ducts  penetrate  the  organ.  The  middle  portion  or  "middle 
lobe"  corresponds  to  that  part  of  the  base  of  the  gland  that  joins  the 
two  lateral  lobes  across  the  middle  line.     It  is  usually  represented 


694 


URINARY  SYSTEM. 


by  a  small,  rounded  prominence  that  presents  into  the  base  of  the 
bladder  immediately  behind  the  internal  urethral  orifice.  This  is 
the  portion  of  the  prostate  which  is  most  likely  to  become  affected  in 
hypertrophy  of  the  gland.  It  presents  as  a  prominent  rounded  mass  into 
the  bladder,  posterior  to  the  urethral  orifice;  or  may  become  partly 
separated  from  the  principal  prostatic  mass  and,  without  being  much 
increased  in  size,  may  interfere  with  micturition  by  blocking  the 
internal  urethral  orifice,  "^Td all- valve"  fashion. 


Fig.  311.— Transverse  Section  of  Prostate  through  the  Verumontanum.  C, 
capsule  of  gland;  D.,  ejaculatory  ducts;  P.,  sinus  pocularis;  P.O.,  a  prostatic 
follicle  opening  upon  floor  of  urethra;  8.,  outside  fibrous  sheath  of  prostate 
gland;  TJ.,  urethra.  In  the  space  between  the  capsule  and  outside  fibrous  sheath 
the  veins  of  the  prostatic  plexus  are  seen  on  section. 


The  prostate  is  traversed  by  the  urethra  and  the  ejaculatory 
ducts.  The  prostatic  portion  is  the  widest  and  most  dilatable  portion 
of  the  urethral  canal.  It  penetrates  the  entire  length  of  the  gland 
from  base  to  apex,  and  is  situated  nearer  the  upper  than  the  lower 
surface.  The  prostatic  urethra  is  about  one  and  one-quarter  inch 
long  and  is  made  up  of  mucous  membrane  and  an  underlying  layer 
of  connective  tissue  which  contains  unstriped  muscular  fibers  and 
elastic  tissue.  The  floor  of  the  prostatic  urethra  is  marked  by  a 
longitudinal  elevation,  nearly  one  inch  in  length,  the  verumontanum. 
At   the    anterior   end   of   the   verumontanum    is   the   mouth   of    the 


SURGICAL  ANATOMY  OF  THE  PROSTATE.  695 

sinus  pocularis,  a  cul-de-sac  which  extends  backward  underneath  the 
verumontanum  for  about  one-fourth  inch.  Upon  or  near  the  margins 
of  the  mouth  of  tiie  sinus  pocularis  are  the  narrow,  slit-like  orifices 
of  the  ejaculatory  ducts.  The  floor  of  the  prostatic  urethra  presents 
upon  either  side  of  the  verumontanum  the  orifices  of  the  ducts  of  the 
j)rostatic  follicles,  from  twenty  to  thirty  in  number. 

Above  and  behind  the  prostate  body,  closely  applied  to  the  base 
of  the  bladder,  between  the  bladder  and  the  rectum,  are  the  vesiculge 
seminales  and  vasa  deferentia.  Each  vas  has  a  vesicula  seminalis  lying 
to  its  outer  side.  The  vasa,  as  they  pass  downward  and  forward  toward 
the  base  of  the  prostate,  approach  each  other  and  just  before  they 
enter  the  prostate  they  join  with  the  ducts  of  the  corresponding 
vesiculae  seminales  to  form  the  common  ejaculatory  ducts.  The  com- 
mon ejaculatory  ducts,  thus  formed,  pierce  the  prostate,  side  by  side 
and  close  together,  at  the  deep  interlobular  notch  that  marks  the 
under  part  of  the  base  of  the  gland.  They  pass  forward  through  the 
prostate,  being  situated  just  beneath  the  urethral  canal,  one  on 
either  side  of  the  middle  line,  and  empty  upon  the  floor  of  the  pro- 
static urethra  close  to,  or  just  within,  the  margins  of  the  sinus 
pocularis. 

The  prostate  gland  is  inclosed  in  its  own  fibrous  capsule,  the 
capsule  proper,  which  is  composed  of  condensed  connective  tissue 
and  is  separate  and  distinct  from  the  fibrous  sheath  or  envelope  that 
is  reflected  around  it  from  the  posterior  layer  of  the  deep  perineal 
fascia  (triangular  ligament).  The  capsule  proper  of  the  prostate 
is  found  to  be  considerably  thickened  in  pathological  conditions 
affecting  the  gland.  The  fibrous  layer  which  is  derived  from  the 
deep  perineal  fascia  invests  the  prostate,  forming  its  external  fibrous 
sheath  or  envelope,  and  is  continued  upward,  beyond  the  base  of 
the  prostate,  upon  the  bladder,  covering  in  the  vesiculs  seminales 
and  serves  to  retain  these  latter  organs  in  close  relationship  with  the 
bladder. 

Blood-supplt. — The  prostate  is  supplied  by  branches  from  the 
internal  pudic,  vesical,  and  hemorrhoidal  arteries.  Its  veins  form 
a  plexus  around  the  base  and  sides  of  the  gland,  receiving  in  front 
the  dorsal  vein  of  the  penis  and  terminating  in  the  internal  iliac 
veins.  The  venous  plexus  is  situated  beneath  the  fibrous  sheath, 
between  this  layer  and  the  true  capsule  of  the  gland. 


696  URINARY  SYSTEM. 

OPERATIONS   UPON   THE  PROSTATE. 

Prostatectomy. — Extirpation  of  the  prostate  gland.  For  the  pur- 
pose of  relieving  the  obstruction  offered  by  the  hypertrophied  gland  to 
the  proper  evacuation  of  the  bladder. 

The  prostate  nlay  be  removed  either  from  within  the  bladder 
through  a  suprapubic  incision  or  else  through  an  incision  which  is 
made  in  the  perineum. 

SuPEAPUBic  Prostatectomy.- — The  operation  of  Beliield,  Mc- 
Grill,  Fuller,  and  Freyer.  Especially  adapted  for  cases  of  enormous 
hypertrophy  and  particularly  of  the  middle  portion  of  the  gland  and 
for  tumors  high  up  and  projecting  decidedly  into  the  bladder.  The 
mortality  is  greater  following  suprapubic  prostatectomy  than  perineal 
prostatectomy. 

The  patient  is  placed  flat  upon  the  table  and  the  bladder  washed 
out  with  boric-acid  solution.  Eight  or  ten  ounces  of  the  fluid  are 
allowed  to  remain  in  the  bladder.  The  rubber  catheter  is  permitted 
to  remain  in  order  to  indicate  the  position  of  the  internal  urethral 
orifice  and  the  position  and  course  of  the  urethra.  The  end  of  the 
catheter  is  closed  with  a  hsemostat  to  prevent  the  fluid  escaping  from 
the  bladder. 

A  suprapubic  cystotomy  is  made  as  already  described,  with  the 
patient  lying  upon  the  back.  The  incision  in  the  abdomen  and  blad- 
der may  be  held  open  with  long,  broad  retractors  and  the  interior  of 
the  bladder  explored.  Calculi  may  be  discovered  in  the  bladder. 
These  are  removed  with  the  forceps  or  scoop.  The  enlarged,  prom- 
inent prostate  is  readily  recognized  when  the  flnger  is  introduced 
into  the  bladder.  The  end  of  the  catheter  is  felt  in  the  bladder  and 
serves  to  locate  the  position  of  the  urethral  orifice. 

The  table  may  now  be  tilted  so  that  the  patient  occupies  the 
Trendelenburg  position,  and  an  incision  is  made  in  the  wall  of  the 
bladder,  over  the  most  prominent  portion  of  the  hypertrophied  pros- 
tate. Usually  a  transverse  incision  is  made  over  the  so-called  middle 
lobe,  just  behind  the  internal  urethral  orifice;  or  an  antero-posterior 
incision  may  be  made  over  one  or  both  lateral  lobes.  The  incision 
is  made  with  the  long,  sharp-pointed  scissors  and  extends  through 
the  entire  thickness  of  the  bladder  wall  down  to  the  proper  capsule 
of  the  prostate.  The  fingers  of  th^  left  hand  are  introdja^ed  into 
the  bladder  to  guide  the  scissors  in  making  the  incision.  Instead  of 
the  scissors  the  sharpened  finger-nail  may  be  used  to  scrape  through 


OPERATIONS  UPON  THE  PROSTATE.  697 

tlic  wall  of  the  bladder.  The  l)ladder  wall  over  the  most  prominent 
l^art  ol'  the  prostate  mass  is  usually  very  tliin,  consisting  of  the 
mucous  layer  only,  and  is  thus  easily  penetrated.  Through  the  open- 
ing which  is  made  the  finger  is  introduced  and,  working  between  the 
wall  of  the  bladder  and  the  prostate,  with  the  finger  closely  applied 
to  the  capsule  of  the  prostate  all  the  time,  the  entire  hypertrophied 
gland  enclosed  in  its  proper  capsule  is  enucleated.     The  gland  may 


Fig.  312. — Suprapubic  Prostatectomy.  The  waU  of  the  bladder  is  incised  over 
the  prominent  portion  of  the  prostate.  Two  fingers  of  the  left  hand  are  intro- 
duced into  the  rectum  to  make  counterpressure  and  facilitate  the  work  of 
enucleating  the  prostate.  The  prostate  is  enucleated  out  of  its  fibrous  sheath. 
P.,  peritoneal  layer;  8. P.,  sheath  of  the  prostate  is  continued  upward  from  the 
base  of  the  prostate,  enclosing  the  seminal  vesicles,  etc.,  and  finally  thins  out 
and  is  lost  upon  the  wall  of  the  bladder.  The  sheath  of  the  prostate  forms  a 
strong  protecting  barrier  against  injury  to  the  rectum  while  the  prostate  is 
being  enucleated.     S.V.,  seminal  vesicles. 

be  removed  in  one  single  mass  or  in  several  pieces,  two  or  three.  It 
can  usually  be  removed  through  a  single  incision.  Occasionally  it 
will  be  necessary  to  make  an  additional  incision  over  a  second  prom- 
inent portion  of  the  gland  before  the  entire  organ  can  be  removed. 
While  the  gland  is  being  enucleated  by  the  fingers  of  the  right  hand 
working  within  the  bladder,  two  fingers  of  the  left  hand,  gloved,  are 


698  URINARY  SYSTEM. 

introduced  into  the  rectum  to  push  the  prostate  mass  up  toward  the 
hand  working  in  the  bladder. 

Especial  care  must  be  exercised;,  in  working  upon  the  posterior 
aspect  of  the  prostate,  not  to  injure  the  rectum.  Working  within 
the  fibrous  sheath  of  the  prostate,  close  to  the  capsule  proper  of  the 
gland,  the  danger  of  injuring  the  rectum  is  minimized  because  the 
strong,  fibrous  sheath  forms  a  strong,  resistant  barrier  between  the 
fingers  and  the  rectum.  In  detaching  the  prostate  mass  from  around 
the  neck  of  the  bladder  it  is  important  again  to  work  close  to  the 
prostate  mass  so  as  not  to  injure  the  sphincter  muscular  apparatus 
of  the  bladder.  The  prostatic  portion  of  the  urethra  is  damaged, 
torn,  and  probably  removed  in  most,  if  not  all,  cases  of  suprapubic 
prostatectomy.  Apparently  without  any  harm  beyond  necessitating 
the  occasional  passage  of  a  sound  to  prevent  subsequent  stricture.  The 
ejaculatory  ducts  are  necessarily  torn  away  from  the  urethra  in  most, 
if  not  all,  cases. 

After  the  enucleation  has  been  completed  it  will  be  found  that 
the  outside  fibrous  sheath  of  the  prostate  is  left  remaining  intact. 
The  cavity  that  remains  after  the  prostate  has  been  removed  is  partly 
obliterated  by  the  collapse  of  its  walls. 

Usually  the  hemorrhage  is  not  excessive  and  ceases  spontaneously, 
or  may  be  controlled  by  irrigation  for  a  minute  with  hot  saline. 
Occasionally  the  hemorrhage  is  severe  and  it  may  be  necessary  to 
tampon  the  bladder  or  the  pocket  out  of  which  the  prostate  has  been 
enucleated. 

A  rubber  drainage-tube  is  introduced  into  the  bladder  through 
the  suprapubic  incision  and  secured  with  a  single  catgut  suture  to 
the  edge  of  the  incision  in  the  bladder.  The  incision  in  the  bladder 
if  unusually  large,  may  be  closed  in  part.  (See  Suprapubic  Cys- 
totomy). A  rubber,  self -retaining  catheter  is  introduced,  into  the 
bladder  through  the  urethra  to  still  farther  facilitate  drainage  and 
to  permit  of  through  and  through  irrigation  of  the  bladder. 

Perineal  Prostatectomy. — This  is  a  very  convenient  route 
for  removal  of  the  prostate,  especially  for  those  of  smaller  size  and 
those  that  are  situated  low  down  in  the  pelvis.  This  method  is 
favorable  for  drainage  and  is  followed  by  a  lower  mortality  than  the 
suprapubic  operation. 

The  patient  is  placed  in  the  lithotomy  position,  with  the  pelvis 
raised  high  upon  a  sandbag  placed  under  the  buttocks.  A  tunneled 
sound  is  introduced  through  the  urethra  into  the  bladder.     It  may 


OPERATIONS  UPON  THE  PROSTATE. 


699 


be  more  convenient  to  introduce  tliis  instrument  before  placing  the 
patient  in  the  lithotomy  position. 

An  incision  is  made  in  the  middle  line  of  the  perineum,  from 
the  base  of  the  scrotum  backward  to  within  one-half  inch  of  the 
anus.  This  incision  is  carried  down  through  the  skin  and  fat  to  the 
deep  layer  of  the  superficial  perineal  fascia.  The  tunnel  of  the  metal 
guide  within  the  urethra  is  recognized  with  the  finger  in  the  wound 
and  the  point  of  the  knife,  guided  by  the  finger-nail,  is  placed  in  the 
groove  of  the  guide,  thus  piercing  the  membranous  part  of  the  urethra 
just  posterior  to  the  bulb.    The  urethra  is  incised  as  far  back  as  the 


Fig.  313. — Incision  for  Perineal  Prostatectomy. 


commencement  of  the  prostatic  portion.  The  opening  in  the  urethra 
is  made  large  enough  to  permit  the  finger  to  be  introduced  into  the 
bladder.  The  bladder  may  then  be. irrigated  before  proceeding  with 
the  next  step  of  the  operation — the  exposure  of  the  prostate  gland. 
From  the  posterior  end  of  the  median  incision,  two  additional 
incisions,  one  on  either  side,  are  carried  backward  and  outward  toward 
the  tuberosities  of  the  ischium.  These  convert  the  incision  into  the 
form  of  an  inverted  Y.  The  lateral  incisions  are  deepened.  The 
attachment  of  the  external  sphincter  ani,  anteriorly,  to  the  midpoint 
of  the  perineum  is  divided  and  the  lower  end  of  the  rectum  separated 
from  its  anterior  attachments  and  displaced  backward  toward  the 
coccyx.  The  prostate  is  situated  above  the  level  of  the  levatores  ani 
and  the  edges  of  these  muscles  are  seen  in  the  incision,  one  on  either 


700 


UEINARY  SYSTEM. 


side  of  the  middle  line.  The  edges  of  the  levators  may  be  drawn 
to  either  side  with  narrow,  blunt  retractors  in  order  to  expose  the 
prostate  more  freely.  The  rectum  is  detached  bluntly  with  the  fingers 
and  displaced  backward,  away  from  the  prostate,  toward  the  coccyx, 
and  while  this  is  being  done  it  is  advantageous  to  insert  one  or  two 
fingers  (with  rubber  glove)  in  the  rectum  and  keep  them  there  while 
this  step  of  the  operation  is  being  accomplished.  After  the  rectum 
has  been  separated  and  displaced  backward  the  prostate  may  be 
brought  into  plain  view  by  making  traction  with  the  tractor,  which 
is  introduced  into  the  bladder  through  the  opening  in  the  urethra. 
The  tractors  of  Young,  Albarran,  Lydston  are  used  for  this  purpose. 


Fig.  315. — Young's  Tractor  Open. 


The  tractor,  closed,  is  passed  through  the  opening  in  the  urethra, 
into  the  bladder  up  beyond  the  prostate  mass,  and  its  blades  then 
spread  by  turning  the  arm  at  the  handle.  With  this  instrument  the 
prostate  mass  is  drawn  down  into  the  incision  in  the  j)erineum  and 
its  entire  posterior  surface  and  base  exposed.  The  rectum  may  be 
drawn  back  toward  the  coccyx,  out  of  the  wsij,  with  a  broad  retractor. 
The  fibrous  sheath  of  the  prostate  is  incised  on  either  side 
according  to  the  method  of  Young,  and  the  prostate  mass  enucleated. 
Two  incisions  are  made,  one  on  either  side  of  the  middle  line, 
extending  nearly  the  entire  length  of  the  prostate  and  about  1  cm. 
deep.  The  two  incisions  approach  each  other  in  front,  being  about 
1.5  cm.  apart  anteriorly  and  1.8  cm.  posteriorly.  The  bridge  of  tissue 
between  these  two  incisions  corresponds  to  the  course  of  the  ejaculatory 
ducts  and  its  preservation  is  necessary  if  the  duets  are  to  be  saved  from 


OPERATIONS  UPON  THE  PROSTATE. 


701 


Fig.  316. — Perineal  Prostatectomy  (Young).  Membranous  urethra  opened  just 
anterior  to  prostate  and  tractor  introduced.  Incision  through  the  sheath  of 
prostate.    Detaching  the  sheath  from  the  right  lobe  with  the  blunt  dissector. 


702 


URINARY  SYSTEM. 


injur)^  The  incisions,  being  1  cm.  deep,  reach  into  the  substance  of 
the  prostate  beyond  the  level  of  the  ducts  and  close  to  the  sides  of  the 
urethral  canal. 

The  fibrous  sheath  is  separated  from  the  prostate  with  the  blunt 
dissector.  It  is  important  to  start  in  the  correct  line  of  cleavage. 
As  this  step  of  the  operation  progresses  the  lobe  is  drawn  more  and 
more  out  of  its  sheath.  The  urethra  is  then  detached  from  the  gland 
first  on  one  side  and  then  on  the  other,  drawing  down  with  the  tractor 


Fig.  317.— Enucleation  of  Middle  Dobe.  The  finger  is  introduced  into  the 
empty,  right  pocket  to  force  a  middle  lobe  into  the  other,  left,  pocket  through 
which  it  may  be  enucleated. 


at  the  same  time.  In  detaching  the  upper  part  of  the  prostate,  that 
part  which  corresponds  to  the  neck  of  the  bladder,  care  must  be  exer- 
cised to  separate  the  "wall  of  the  bladder  without  injuring  it.  Too 
much  force  must  not  be  used  with  the  tractor  because,  the  support 
having  been  removed  below  by  detaching  the  prostate  all  around,  there 
is  danger  of  tearing  abruptly  through  the  mucous  membrane  of  the 
bladder.  The  partially  enucleated  mass  may  be  seized  with  forceps 
for  the  purpose  of  making  traction  and  thus  facilitating  its  removal. 
Each  half  of  the  prostate  mass  is  enucleated  from  the  corresponding 
portion  of  the  sheath  without  injuring  the  ejiaculatory  ducts  and 
without  destroying  the  prostatic  portion  of  the  urethra. 


OPERATIONS  UPON  THE  PROSTATE.  703 

If,  after  both  lobes  have  been  enucleated,  a  median  portion  still 
remains,  this  may  be  drawn  down  with  tlie  tractor  so  that  it  will 
present  in  either  one  of  the  empty  pockets  from  which  the  lateral 
lobes  have  been  extirpated,  assisting  this  maneuver  by  pushing  wnth 
the  finger  in  the  other  pocket,  and  while  the  mass  is  steadied  in  this 
position  it  may  be  seized  and  enucleated.  Larger  middle  lobes  are 
thus  readily  enucleated.  A  smaller  enlargement  in  the  shape  of  a 
transverse  bar  may  be  directed  into  one  of  the  empty  pockets  and 
its  end"  seized  with  a  bullet  forceps,  and  while  traction  is  made  the 
mass  is  carefully  enucleated. 

Two  rubber  tubes,  tied  together,  side  by  side,  are  introduced 
through  the  opening  in  the  deep  urethra  into  the  bladder,  for  the 
purpose  of  drainage.  The  bladder  may  readily  be  irrigated  through 
these  tubes  if  the  necessity  arises. 

The  wound,  including  the  two  empty  prostatic  pockets,  is  packed 
loosely  with  iodoform  gauze,  and  the  incision  in  the  skin  partly 
closed  with  several  silk  sutures. 

The  perineal  tubes  are  removed  at  the  end  of  six  or  seven  days. 

Prostatotomy  (Bottini's  Operation). — ^This  operation  consists  in 
cutting  the  prostatic  mass  with  a  heated  blade  introduced  into  the 
bladder  through  the  urethra.  The  operation  is  especially  adapted 
to  old  and  feeble  subjects  and  those  w^ho  suffer  from  kidney  disease. 

The  necessary  apparatus  consists  of  an  incisore  prostatico,  a 
battery,  and  a  rheostat  to  regulate  the  current  accurately. 

One  should  have  previously  made  an  examination  with  the  cys- 
toscope  for  stone,  etc.  The  patient  lies  upon  the  back  with  his  legs 
hanging  over  the  end  of  the  table  and  the  thighs  spread  apart.  The 
bladder  should  contain  about  6  ounces  of  boric-acid  solution. 

Usually  sufficient  local  anaesthesia  is  obtained  by  the  use  of  a 
solution  of  cocain  which  is  thrown  into  the  urethra  and  stripped 
backward  into  the  posterior  urethra  with  the  finger,  or  a  general 
ansesthetic  may  be  employed.  With  the  finger  in  the  rectum  the 
size  and  the  shape  of  the  prostatic  tumor  may  be  determined. 

The  incisore  is  introduced  into  the  bladder  beyond  the  enlarged 
prostate  and  its  nose  turned  downward  toward  the  base  of  the  blad- 
der, so  that,  as  it  is  slowly  withdrawn,  it  catches  or  hooks  upon  the 
prostatic  mass.  The  extremity  of  the  instrument  may  be  felt  with 
the  finger  in  the  rectum  through  the  bladder  wall  above  the  prostatic 
tumor.  The  instrument  is  now  held  firm  and  steady  in  the  whole  of 
the  left  hand  and  the  current  closed  and  regulated  by  the  rheostat 


701  UEIXAPvY  SYSTEM. 

until  snfficientlv  strong  to  give  a  red  heat,  "n-Mch  usually  requires 
fifteen  seconds.  Xow,  slowly  turning  the  screw  in  the  handle  of  the 
instrmnent,  the  heated  blade  is  gradually  withdrawn,  thus  burning 
a  furrow  through  the  prostatic  mass.  If  the  ear  is  held  near  the 
symphysis,  a  sizzling  sound  can  be  heard.  If,  in  withdrawing  the 
blade,  we  note  increased  resistance  in  the  mass,  the  current  is  aug- 
mented; if  too  little  resistance  to  the  blade — if  it  cuts  too  easily — 
the  current  is  correspondingly  diminished.  After  the  incision  has 
been  made  sufficiently  long  the  blade  is  shoTed  back  with  a  little 
increase  of  the  current. 

Several  such  incisions  or  channels  should  be  made  in  the  prostatic 
mass,  usually  three:  one  in  the  middle  line,  toward  the  rectum  with 
the  beak  of  the  instrument  directed  downward,  and  two  lateral,  one  on 
each  side  of  the  middle  line.  The  iacision  through  the  upper  part 
of  the  prostate  with  the  beak  of  the  instrument  directed  upward  toward 
the  symphysis  may  well  be  omitted,  because,  in  the  first  place,  it  is 
unnecessary  and,  in  the  second,  it  is  dangerous  on  account  of  the  ease 
with  which  the  blade  may  cut  through  the  neck  of  the  bladder  into 
the  space  of  Eetzius.  Before  commencing  the  incisions  the  beak  of 
the  instrument  within  the  bladder  should  be  felt  for  above  the  pro- 
static mass  with  the  finger  in  the  rectum  in  order  to  make  certain 
that  it  has  not  slipped  forward,  over  the  prostatic  mass,  into  the  deep 
urethra. 

The  entire  operation  should  occupy  from  five  to  ten  minutes. 

The  permanent  benefit  that  is  derived  from  this  operation  depends 
upon  the  contraction  which  accompanies  the  cicatrization  of  the  fur- 
rows that  are  burned  in  the  prostatic  mass. 

The  incisor  resembles  a  lithotrite,  having  a  male  and  a  female 
blade,  the  male  blade  fitting  into  the  female  and  consisting  of  plati- 
num iridium,  which  may  be  heated  to  any  degree  by  the  electric 
current,  whose  strength  is  regulated  by  the  rheostat. 

By  turning  the  screw  at  the  handle  the  male  blade  is  withdrawn 
from  the  groove  in  the  female  blade,  and  is  thus  made  to  cut  or  burn 
its  way  through  the  hypertrophied  prostatic  mass. 

The  shaft  of  the  instrument  is  hollow,  so  that  it  may  be  supplied 
with  a  current  of  cold  water,  which  flows  in  through  one  tube  and  out 
through  another.  The  openings  of  these  tubes  both  present  near  the 
handle.  The  cold-water  current  is  for  the  purpose  of  keeping  that 
part  of  the  instrument  cool  which  rests  in  the  anterior  part  of  the 
urethra. 


OPERATIONS  UPON  THE  PROSTATE.  705 

The  incisor  as  improved  by  Young  has  many  advantages.  The 
beak  of  Young's  instrument  is  more  sharply  curved  and  therefore  is 
less  liable  to  slip  forward  over  the  prostatic  mass  into  the  deep  urethra 
and  it  is  provided  with  four  interchangeable  blades  of  different  siz:e8 
and  different  degrees  of  curvature  so  that  an  appropriate  blade  for 
each  case  can  be  selected. 

Immediately  before  using  the  instrument  it  should  be  tested  with 
the  current,  and  an  observation  made  upon  the  rheostat  to  determine 
just  what  degree  of  current  is  necessary  to  bring  the  blade  to  the 
proper  heat;  usually  about  45  amperes  are  required.  The  screw  in 
the  handle  permits  of  an  incision  up  to  4  cm.  in  length  being  made. 

This  operation  has  been  modified  by  Chetwood,  who  makes  a 
perineal  incision  for  the  purpose  of  introducing  the  incisor.  This  is 
a  decided  advantage.  The  incisor  of  Chetwood  is  a  very  satisfactory 
instrument  for  dividing  the  tissues. 


45 


PART  IX. 

THE  UPPER  EXTREMITY. 


THE  AXILLA. 

The  Axilla  is  a  four-sided  pyramidal  space.  Its  apex  is  above, 
and  corresponds  to  the  depression  upon  the  upper  surface  of  the  first 
rib,  external  to  the  attachment  of  the  tendon  of  the  scalenus  anticus 
muscle^  where  the  subclavian  artery  enters  the  axillary  space  to  be- 
come the  axillary.  The  base  of  the  axilla  corresponds  to  the  fold  of 
skin  and  fascia  which  is  stretched  between  the  edge  of  the  pectoralis 
major  in  front  and  that  of  the  latissimus  dorsi  behind. 

The  anterior  wall  of  the  axilla  is  made  up  of  the  pectoralis  major 
and  pectoralis  minor ;  the  posterior  wall  is  formed  by  the  subscapularis 
and  the  tendon  of  the  latissimus  dorsi  and  the  teres  major.  The  inner 
wall  corresponds  to  the  side  of  the  chest,  and  is  made  up  of  the  first, 
second,  third,  and  fourth  ribs  and  corresponding  intercostal  muscles 
and  the  upper  serrations  of  the  serratus  magnus.  The  outer  wall  of 
the  axilla  is  a  narrow  space,  which  is  included  between  the  anterior 
and  posterior  walls  and  corresponds  to  the  floor  of  the  bicipital  groove. 
In  the  bicipital  groove  is  lodged  the  long  tendon  of  the  biceps.  The 
coraco-brachialis  muscle,  which  arises  from  the  coracoid  process,  de- 
scends in  the  outer  part  of  the  axillary  space,  lying  close  to  the 
humerus. 

To  the  anterior  lip  of  the  bicipital  groove  is  attached  the  tendon 
of  the  pectoralis  major,  and  to  its  posterior  lip  are  attached  the  ten- 
dons of  the  latissimus  dorsi  and  teres  major. 

The  contents  of  the  axilla  consist  of  the  axillary  artery  and  vein, 
the  large  nerve-trunks  which  are  derived  from  the  brachial  plexus, 
lymphatic  vessels  and  nodes,  and  a  mass  of  loose  connective  tissue  and 
fat  which  is  continuous  with  the  connective  tissue  and  fat  of  the  root 
of  the  neck  and  the  mediastinum. 

The  Axillary  Artery. — The  axillary  artery  is  the  continuation 
of  the  subclavian,  and  passes  through  the  axillary  space  from  its  apex 
to  its  base,  where  it  is  prolonged  downward  into  the  arm  as  the  brach- 
ial. The  vessel  passes  through  the  upper  part  of  the  axillary  space, 
(706) 


AXILLA. 


707 


lying  close  to  its  anterior  wall.  The  lower,  or  outer,  portion  of  the 
artery  lies  close  to  the  humerus,  beneath  the  edge  of  the  coraco-braehi- 
alis,  resting  upon  the  tendon  of  the  latissimus  dorsi,  and  covered  by 
the  pectoralis  major.  The  axillary  vein,  which  is  sometimes  double, 
accompanies  the  artery,  lying  below  it,  and  both  artery  and  vein  are 
in  close  relation  with  the  nerve-trunks  which  traverse  the  axillary 
space.  With  the  arm  extended  to  a  right  angle,  the  course  of  the 
artery  is  nearly  straight,  and  corresponds  to  an  imaginary  line  which 
is  drawn  from  the  junction  of  the  inner  and  ini<ldle  thirds  of  the  clav- 


Fig.  318. — AxiHary  Region.  Costo-coracoid  membrane  has  been  cleared 
away  to  show  upper  part  of  the  axiUary  vessels,  etc.  C.V.,  cephalic  vein; 
EX. C.N. ,  external  cutaneous  nerve;  IN.C.N.,  internal  cutaneous  nerve; 
M.N.,  median  nerve;  8.V.,  subscapular  vein;   U.N.,  ulnar  nerve. 


icle  to  a  point  upon  the  front  of  the  elbow  midway  between  the  two 
condyles;  with  the  arm  hanging  by  the  side,  the  artery  describes  a 
curve  which  is  convex  upward  and  outward. 

After  the  pectoralis  major  has  been  separated  from  its  attach- 
ment to  the  clavicle  and  reflected  downward,  the  pectoralis  minor, 
together  with  the  costo-coracoid  membrane,  will  be  exposed.  The 
costo-coracoid  membrane  is  a  r,ather  thickened  sheath  of  fascia  which 
reaches  from  the  inner  border  of  the  pectoralis  minor  upward,  to  be 
attached  to  the  under  surface  of  the  clavicle  and  to  the  first  rib;  it 
is  simply  a  reflection  of  the  deep  fascia  which  invests  the  pectoralis 


708  UPPER  EXTREMITY. 

minor,  and  serves  to  cover  in  the  upper,  or  first,  part  of  the  axillary 
vessels  and  adjoining  structures. 

The  axillary  artery  is  crossed  about  its  middle  by  the  peetoralis 
minor  muscle,  and  may  be  conveniently  considered  in  three  parts. 
The  upper,  or  first,  part  of  the  artery  reaches  from  its  commencement 
at  the  first  rib  to  the  inner  border  of  the  peetoralis  minor,  and  is  not 
exposed  until  after  the  costo-coracoid  membrane  has  been  cleared 
away ;  the  second  part  of  the  artery  is  that  portion  which  lies  behind 
the  peetoralis  minor  muscle,  and  the  third  is  that  part  which  reaches 
from  the  outer  border  of  peetoralis  minor  to  the  point  below  where  it 
becomes  the  brachial. 

In  the  first  part  of  its  course  the  three  trunks  of  the  brachial 
plexus  lie  above  the  axillary  artery.  In  the  second  part  of  its  course 
one  trunk  lies  above,  one  behind,  and  one  below  it.  In  the  third  part 
the  cords  of  the  brachial  plexus  communicate  with  each  other,  sur- 
rounding the  axillary  arter}^,  and  divide  into  a  number  of  branches  to 
supply  the  upper  extremity.  The  median  nerve  lies  external  to  the 
artery,  taking  one  root  from  the  external  cord  of  the  plexus  and  a 
second  root  from  the  internal  cord,  the  latter  root  passing  across  the 
front  of  the  artery.  The  external  cutaneous  nerve  also  lies  to  the 
outer  side  of  the  vessel,  being  derived  from  the  outer  cord  of  the 
plexus.  To  the  inner  side  of  the  artery,  and  derived  from  the  inner 
cord,  are  the  ulnar,  internal  cutaneous,  and  lesser  internal  cutaneous 
nerves.  Derived  from  the  posterior  cord  of  the  brachial  plexus  and 
situated  behind  the  artery  are  the  posterior  circumflex  and  the  mus- 
culo-spiral  nerves.  Immediately  after  its  origin  the  circumflex  passes 
directly  backward  between  the  subscapularis  and  latissimus  dorsi  (and 
teres  major)  muscles,  and  is  distributed  to  the  deep  surface  of  the 
deltoid. 

The  cephalic  vein  pierces  the  costo-coracoid  membrane  and  passes 
acrosL!  the  first  part  of  the  axillary  artery  to  empty  into  the  axillary 
vein. 

The  lymphatic  vessels  and  nodes  are  intimately  related  to  rhe 
axillarj'^  vessels  along  their  whole  course  within  the  axilla. 

From  the  upper,  or  first,  part  of  artery  are  given  off  the  superior 
thoracic  and  acromial  thoracic  branches,  which  are  distributed  to  the 
anterior  wall  of  the  axilla  and  to  the  axillary  contents.  A  branch  from 
the  acromial  thoracic  is  found  in  company  with  the  cephalic  vein  in 
the  groove  between  the  deltoid  and  peetoralis  major  muscles  (Mohren- 
heitn's  fossa). 


ARM.  709 

At  the  lower  border  of  the  pectoralis  minor  the  lonj;  thoracic  is 
given  off;  this  branch  passes  downward  close  to  the  lower  border  of 
this  muscle,  lying  beneath  the  edge  of  the  pectoralis  major,  and  ram- 
ifies upon  the  side  of  the  chest. 

Still  lower,  and  close  to  the  posterior  wall  of  the  axilla,  the  artery 
gives  off  the  subscapular,  a  large  branch  which  descends  upon  the 
posterior  wall  of  the  axilla,  along  the  outer  border  of  the  subscapularis 
muscle ;  it  is  accompanied  by  the  large  subscapular  nerve,  and  enters 
and  supplies  the  latissimus  dorsi.  External  to  this  branch  is  given 
off  the  posterior  circumflex,  which  passes  backward  between  the  latissi- 
mus dorsi  and  subscapularis  muscles  together  with  the  circumflex 
nerve;  they  wind  around  the  surgical  neck  of  the  humerus  beneath 
the  deltoid,  which  they  supply.  The  axillary  vessels  and  adjoining 
nerves,  etc.,  in  the  upper,  or  inner,  part  of  the  axillary  space,  are 
located  close  to  the  anterior  wall,  and  in  the  lower,  or  outer,  part  of 
the  axilla  they  are  found  close  to  the  humerus,  resting  upon  the 
tendon  of  the  latissimus  dorsi  and  beneath  the  edge  of  the  coraco- 
braclnalis.  Branches  of  the  axillary  artery  ramify  upon  the  anterior 
and  posterior  walls  of  the  axillary  space,  and,  descending  upon  the 
inner  wall,  side  of  the  chest,  posteriorly,  is  the  long  thoracic  nerve, 
which  supplies  the  serratus  magnus;'  the  middle  of  the  axilla  is, 
therefore,  free  for  incisions  for  abscess,  etc.;  if  it  is  desired  to  ex- 
tirpate completely  the  axillary  contents,  it  is  well  to  commence  by 
making  a  clean  dissection  of  the  main  vessels  and  nerves. 

THE  ARM. 

Upon  the  front  of  the  arm  there  is  seen  a  prominent  spindle- 
shaped  mass,  which  consists  of  the  belly  of  the  biceps  and,  joined  to 
its  inner  side,  the  coraco-brachialis  muscle.  Occupying  the  inner  side 
and  back  of  the  arm  is  a  thick  mass  of  muscle,  the  triceps.  Upon  the 
outer  side,  above,  covering  over  the  shoulder-joint,  is  a  large  mass  of 
muscle,  the  deltoid.  Beneath  the  deltoid,  between  it  and  the  surgical 
neck  of  the  humerus,  the  circumflex  nerve  and  the  circumflex  arteries 
are  found.  The  circumflex  nerve,  although  well  protected  by  the  mass 
of  deltoid  muscle,  on  account  of  its  relation  with  the  neck  of  the 
humerus  is  often  injured  by  blows  and  falls  upon  the  shoulder,  with 
a  resulting  disability  of  the  deltoid. 

Vessels  of  Arm.  The  Brachial  Artery. — In  the  depression 
corresponding  to  the  inner  margin  of  the  biceps  and  coraco-brachialis. 


710  UPPER  EXTREMITY. 

beneath  the  deep  fascia^,  lies  the  brachial  artery.  The  brachial  artery 
is  the  continuation  of  the  axillary ;  it  passes  down  along  the  inner  side 
of  the  arm  in  the  space  between  the  anterior  muscular  mass^  biceps,  etc., 
and  the  inner  muscular  mass,  triceps;  externally  and  behind,  the 
artery  rests  against  the  humerus,  and  below  the  bend  of  the  elbow  it 
divides  into  the  radial  and  ulnar. 

The  linear  guide  to  the  artery  with  the  arm  abducted  is  a  line 
drawn  from  the  coracoid  process  to  a  point  upon  the  front  of  the 
elbow,  midway  between  the  condyles ;  the  muscular  guide  is  the  inner 
edge  of  the  biceps  and  the  coraco-brachialis  muscles. 

The  brachial  artery  is  covered  by  the  integument  and  deep  fascia, 
and  is  accompanied  by  two  veins,  vense  comites,  which  lie  directly 
upon  the  vessel  and  anastomose  with  each  other  by  numerous  trans- 
verse branches.  Above  the  median  nerve  lies  to  the  outer  side  of  the 
brachial  artery,  crosses  the  artery  about  its  middle,  and  below  lies  to 
its  inner  side;  the  ulnar  and  internal  cutaneous  nerves  are  situated 
upon  the  inner  side  of  the  artery,  the  ulnar  resting  upon  the  inner 
head  of  the  triceps  and  gradually  getting  farther  away  from  the  ar- 
tery as  it  descends  to  reach  the  back  of  the  internal  condyle.  Behind 
the  artery,  in  the  upper  part  of  the  arm,  the  musculo-spiral  nerve  is 
located. 

The  basilic  vein  runs  parallel  with  the  brachial  artery,  lying 
superficial  to  it  and  rather  to  its  inner  side.  One  may  meet  this  vein 
in  making  the  incision  to  expose  the  brachial  artery.  In  the  loAver 
half  of  the  arm  this  vein  is  separated  from  the  artery  by  the  deep 
fascia,  but  about  the  middle  of  the  arm  it  pierces  the  deep  fascia,  and 
thus  gets  into  closer  relation  with  the  artery.  In  the  upper  part  of 
the  arm  the  basilic  joins  the  venge  comites  to  form  the  axillary 
vein.  Along  the  outer  side  of  the  arm,  superficial  to  the  deep  fascia, 
runs  the  cephalic  vein ;  above  this  vein  is  found  in  the  groove  between 
the  pectoralis  major  and  the  deltoid,  and,  after  piercing  the  costo- 
coracoid  membrane,  passes  across  the  first  part  of  the  axillary  artery 
to  empty  into  the  axillary  vein. 

At  the  elbow,  upon  the  front  aspect  of  the  arm,  there  is  a  tri- 
angular space  with  its  apex  directed  downward;  the  inner  border  of 
the  space  is  formed  by  the  pronator  radii  teres,  passing  obliquely 
downward  and  outward  from  the  internal  condyle;  the  outer  border 
is  formed  by  the  spinator  longus,  and  its  floor  by  the  brachialis  anti- 
cus  and  supinator  brevis.  In  this  space  are  found  the  tendon  of  the 
biceps,  the  brachial  artery,  and  its  accompanying  veins,  the  median 


ARM. 


711 


Fig.  319.— Section  through  Middle  of  Right  Arm.  B.A.,  brachial  artery; 
C.T.,  cephalic  vein;  M.N.,  median  nerve;  M.8.N.,  musculo-spiral  nerve; 
V.N.,  ulnar  nerve. 


713  UPPER  EXTREMITY. 

and  the  musculo-spiral  nerves,  and  the  bifurcation  of  the  brachial 
artery  into  the  radial  and  ulnar,  which  occurs  about  one  inch  below 
the  bend  of  the  elbow.  In  this  space  the  median  nerve  is  about  half 
an  inch  to  the  inner  side  of  the  brachial  artery,  owing  to  the  latter's 
verging  outward,  away  from  the  nerve,  toward  the  middle  line. 

The  musculo-spiral  nerve  lies  in  the  outer  part  of  the  space  upon 
the  supinator  brevis,  and  is  covered  by  the  overlapping  edge  of  the 
supinator  longus.  This  region  is  covered  by  the  skin,  superficial  and 
deep  fascia.  The  skin  of  this  region  has  a  marked  tendency  to  retract 
when  cut,  and  this  should  be  remembered  in  marking  out  the  flaps  for 
exarticulation  at  the  elbow-joint.  Lying  just  beneath  the  skin  upon 
the  deep  fascia  is  the  median  cephalic  vein  externally,  and  the  median 
basilic  internally.  The  latter,  the  median  basilic,  is  separated  from 
tlie  brachial  artery,  not  only  by  deep  fascia,  but  also  by  a  fibrous 
expansion  which  is  given  ofi  from  the  biceps  tendon  to  the  deep  fascia 
of  the  forearm.  The  median  cephalic  is  the  vein  selected  by  preference 
for  intravenous  infusion. 

The  Eadial  Artery. — From  its  origin  below  the  bend  of  the 
elbow  the  radial  passes  somewhat  outward  and  then  downward  upon 
the  outer  side  of  the  anterior  aspect  of  the  forearm ;  it  lies  superficial, 
tiiough  partly  covered  by  the  overlapping  edge  of  the  supinator  longus. 
In  its  course  it  rests  upon  the  tendon  of  the  biceps,  the  supinator 
brevis,  the  radial  origin  of  the  flexor  sublimis  digitorum,  the  pronator 
radii  teres,  the  flexor  longus  poUicis,  and  the  pronator  quadratus.  In 
the  lower  part  of  the  forearm,  just  above  the  wrisc,  the  artery  lies 
beneath  the  integument  and  the  deep  fascia,  to  the  outer  side  of  the 
tendon  of  the  flexor  carpi  radialis,  between  it  and  the  tendon  of  the 
supinator  longus. 

In  the  upper  part  of  the  forearm  the  artery  is  accompanied  by 
the  radial  branch  of  the  musculo-spiral  nerve,  which  lies  to  its  outer 
side.    Usually  two  venae  comites  accompany  the  artery. 

At  the  wrist  the  radial  artery  curves  around  the  outer  side  of 
the  joint,  beneath  the  extensor  tendons  of  the  thumb  and  resting  upon 
the  external  lateral  ligament ;  it  then  passes  across  the  posterior  surface 
of  the  scaphoid  and  trapezium,  and  then  forward,  through  the  opening 
in  the  first  dorsal  interosseous  muscle,  into  the  palm  of  the  hand. 

In  the  hand  the  radial  artery  is  situated  deep  and  passes  from 
without  inward,  resting  upon  the  bases  of  the  metacarpal  bones  and 
the  anterior  interosseous  muscle,  covered  by  all  the  structures  of  the 
hand :  tendons,  nerves,  superficial  arch,  etc.    "Upon  reaching  the  inner 


ARM. 


713; 


Fig.  320.— Section  through  Middle  of  Right  Forearm. 
E.D.,  extensor  digit,  com.;  E.I.,  extensor  indicis;  E.M., 
extensor  min.  digit.;  E.O.,  extensor  os.  metacarpi  pol.; 
E.R.B.,  extensor  carp.  rad.  brev. ;  E.R.L.,  extensor  carp, 
rad.  long.:  E.S.,  extensor  secundi;  E.U.,  extensor  carp, 
ulnar;  F.F.,  flexor  profund.  dig.;  F.L.,  flexor  long,  pol.; 
F.Ii.,  flexor  carp,  rad.;  F.S.,  flexor  digit,  sublim.;  F.U., 
flexor  carp,  ulnar.;  I.A.N.,  anterior  interos.  art.  and  nerve: 
M.N.,  median  nerve;  P.L.,  palmaris  longus;  P.R.,  pronator 
radii;  R.A.,  radial  art.;  S.L.,  supinat.  long.;  [7..4.A'.,  ulnar 
art.  and  nerve. 


714  UPPER  EXTREMITY. 

side  of  the  hand  it  anastomoses  with  the  communicating  branch  from 
tlie  ulnar,  and  in  this  way  completes  the  deep  palmar  arch.  The  deep 
palmar  arch  is  located  one  finger's  breadth  nearer  the  wrist- joint  than 
the  superficial  palmar  arch.  The  deep  arch  is  accompanied  by  the 
deep  branch  of  the  ulnar  nerve.  From  the  deep  arch  are  given  off 
the  palmar  interosseous  branches ;  these  descend  upon  the  interosseous 
muscles  between  the  metacarpal  bones,  and  at  the  clefts  of  the  fingers 
anastomose  with  the  branches  from  the  superficial  arch. 

The  Ulnar  Aetert. — Immediately  after  its  origin  the  ulnar 
artery  approaches  the  inner  side  of  the  forearm,  passing  deep  beneath 
the  superficial  flexors,  and  lying  upon  the  flexor  profundus  digitorum ; 
the  upper  half  of  the  artery  is  thus  covered  by  the  superficial  flexors 
(pronator  radii  teres,  flexor  carpi  radialis,  palmaris  longus,  and  flexor 
sublimis  digitorum)  ;  in  the  lower  half  of  its  course  the  ulnar  artery 
is  still  found  resting  upon  the  flexor  profundus  digitorum,  but  it  is 
rather  more  superficial  and  lies  between  the  tendon  of  the  flexor 
carpi  ulnaris  internally  and  the  tendons  of  the  flexor  sublimis  digi- 
torum externally.  The  artery  is  accompanied  by  the  ulnar  nerve, 
which  lies  to  its  inner  side;  in  the  upper  part  of  the  forearm  the 
median  nerve  lies  to  the  inner  side  of  the  artery,  but  a  short  distance 
below  it  crosses  to  its  outer  side.  The  artery  is  accompanied  by  venae 
comites.  Just  below  its  origin  the  ulnar  gives  off  the  interosseous, 
wliich  divides  into  an  anterior  and  a  posterior  interosseous  branch. 
The  anterior  passes  down  the  front  of  the  forearm,  resting  upon  .the 
interosseous  membrane;  the  posterior  passes  through  an  opening  in 
the  Lipper  part  of  the  interosseous  membrane,  and  runs  down  the 
back  of  the  forearm  between  the  superficial  and  deep  layers  of  muscles. 

At  the  wrist  the  ulnar  artery  lies  superficial,  passing  across  the 
anterior  annular  ligament,  on  the  ulnar  side  of  the  hand,  just  to  the 
radial  side  of  the  pisiform  bone,  with  the  ulnar  nerve  lying  to  its 
inner  side;  here  it  turns  outward  toward  the  radial  side  of  the  hand 
and  anastomoses  with  a  branch  (superficial)  from  the  radial,  thus 
forming  the  superficial  palmar  arch. 

In  the  hand  the  superficial  palmar  arch  is  about  on  a  level  with 
the  palmar  surface  of  the  thumb  when  it  is  abducted  and  is  covered 
by  the  skin  and  palmar  fascia,  resting  upon  the  flexor  tendons,  etc.; 
it  gives  off  digital  branches,  four  in  number,  which  pass  downward 
and  after  anastomosing  with  the  palmar  interosseous  branches,  from 
the  deep  palmar  arch,  at  the  clefts  of  the  fingers,  divide  into  two 
branches  to  supply  the  contiguous  sides  of  the  fingers. 


HAND.  715 

The  McscuLO-sriRAL  Xerve. — The  musculo-spiral  nerve  passes 
down  the  back  of  the  arm.  It  is  lodged  in  the  musculo-spiral  groove 
upon  the  posterior  surface  of  the  humerus  between  the  inner  and 
outer  heads  of  the  triceps  muscle  and  covered  by  Ihe  long  head  of 
this  muscle.  In  its  course  it  crosses  the  posterior  surface  of  the 
humerus  obliquely  from  above  downward,  and  from  within  outward, 
and  at  the  elbow-joint  is  found  in  front  of  the  external  condyle  be- 
neath the  supinator  longus.  The  nerve  is  accompanied  by  the  supe- 
rior profunda  branch  of  the  brachial  artery. 

The  IIedian  Nerve. — In  the  upper  arm  the  median  nerve  is 
closely  related  with  the  brachial  artery.  In  the  forearm  it  lies  be- 
neath the  flexor  sublimis  muscle,  resting  upon  the  flexor  profundus 
digitorum.  Just  above  the  annular  ligament  this  nerve  becomes  more 
superficial,  lying  to  the  inner  side  of  the  tendon  of  the  flexor  carpi 
radialis. 

The  Ulnar  Nerve. — In  the  upper  arm  the  ulnar  nerve  lies  some 
little  distance  to  the  inner  side  of  the  brachial  artery,  resting  upon 
the  inner  head  of  the  triceps,  beneath  the  deep  fascia.  At  the  elbow 
the  ulnar  nerve  lies  behind  the  joint  in  the  groove  between  the  in- 
ternal condyle  and  the  olecranon  process;  it  then  swings  forward, 
and  is  continued  down  the  anterior  aspect  of  the  forearm,  resting 
upon  the  flexor  profundus  digitorum  beneath  the  flexor  carpi  ulnaris 
and  Ivinor  close  to  the  inner  side  of  the  ulnar  arten^ 


THE  HAND. 

Beneath  the  integument  in  the  palm  of  the  hand  is  the  palmar 
fascia.  This  is  a  dense,  aponeurotic  layer  intimately  joined  to  the 
integument. 

Beneath  the  palmar  fascia  are  the  flexor  tendons,  superficial  and 
deep  palmar  arches,  nerves,  etc.  As  the  flexor  tendons  pass  across 
the  wrist-joint  into  the  palm  of  the  hand  they  are  bound  down  by 
the  anterior  annular  ligament.  The  extensor  tendons,  as  they  pass 
over  the  back  of  the  wrist-joint  into  the  hand,  are  bound  down  by 
the  posterior  annular  ligament. 

Beneath  the  anterior  annular  ligament  the  flexor  tendons  are 
inclosed  within  a  synovial  sheath,  which  extends  for  a  short  distance 
upward  into  the  forearm  and  downward  into  the  palm  of  the  hand. 
From  this  common  sheath  there  are  given  off  two  processes,  one  of 
which  accompanies   and   envelops  the   tendon   of   the   flexor   longus 


716  UPPER  EXTPtEMITY. 

pollicis  into  the  thumb;  the  other  accompanies  the  flexor  tendons 
of  the  little  finger  to  their  destination. 

The  sheaths  which  surround  the  tendons  of  the  other  fingers — 
i.e.,  the  index,  middle,  and  ring — do  not,  as  a  rule,  reach  beyond  the 
metacarpo-phalangeal  articulation,  and  do  not  communicate  with 
this  common  flexor  sheath.  This  fact  is  important  in  determining^ 
the  extension  of  inflammatory  processes  which  involve  the  tendon 
sjieaths  of  the  fingers  up  into  the  hand  and  forearm.  Inflammatory 
processes  which  involve  the  thumb  and  little  finger  are  found  more 
apt  to  extend  into  the  hand  and  forearm  than  those  of  the  other 
fingers. 

The  hand  gets  its  arterial  supply  from  the  radial  and  ulnar  ar- 
teries (see  description  of  these  vessels). 

The  Nerve-supply  of  the  Hand. — The  nerve-supply  of  the  hand 
is  derived  from  the  median  and  ulnar  and  musculo-spiral  nerves. 
The  median  nerve  passes  into  the  palm  of  the  hand  beneath  the 
annular  ligament;  the  ulnar  nerve  passes  into  the  palm  of  the  hand 
across  the  annular  ligament :  i.e.,  in  company  with  the  ulnar  artery. 
In  the  hand,  in  close  relation  to  the  superficial  arch,  the  median  and 
ulnar  nerves  give  off  their  digital  branches,  which  supply  the  in- 
tegument of  the  palmar  aspect  of  the  fingers  with  sensation,  the 
ulnar  supplying  the  little  finger  and  half  the  ring  finger,  the  median 
supplying  the  other  fingers. 

The  dorsal  aspect  of  the  hand  and  the  fifth,  fourth,  and  part 
of  the  third  fingers  are  supplied  by  the  ulnar  nerve;  the  thumb  and 
the  second  and  part  of  the  third  fingers  are  supplied  by  the  radial 
nerve,  which  is  a  branch  of  the  musculo-spiral. 

All  the  interossei,  both  anterior  and  posterior,  and  the  two  inner 
lumbrieaies  are  supplied  by  the  deep  branch  of  the  ulnar  nerve  which 
accompanies  the  deep  palmar  arch;  the  two  outer  lumbrieaies  are 
supplied  by  the  median. 

A  collection  of  pus  in  the  palm  of  the  hand  may  be  situated 
superficially  beneath  the  skin,  between  it  and  the  palmar  fascia,  or 
deep,  beneath  the  palmar  fascia  or  within  the  proper  synovial  sheaths 
of  the  flexor  tendons. 

Incisions  into  the  palm  of  the  hand  may  be  freely  made  without 
troublesome  hemorrhage,  if  placed  over  the  metacarpal  bones  and 
below  the  line  of  the  superficial  palmar  arch. 

Lig-ations.  The  Axillary  Aetery. — The  axillary  artery  is  not 
often  exposed  for  the  purpose  of  ligation,  but  frequently  the  artery  and 


LIGATIONS.  717 

vein  and  adjoining  structures  are  laid  bare  during  the  course  of  op- 
erations whicli  require  a  thorough  cleaning  out  of  the  axilla. 

A  ligature  may  be  applied  to  the  third  part  of  the  axillary  artery 
as  it  lies  upon  the  tendon  of  the  latissimus  dorsi  close  to  the  hu- 
merus. The  arm  should  be  abducted  from  the  side  of  the  chest  to  a 
right  angle  and  slightly  flexed  at  the  elbow-joint,  in  order  that  the 
structures  may  not  be  placed  too  much  upon  the  stretch;  with  the 
arm  in  this  position  the  course  of  the  artery  corresponds  to  a  line 
drawn  from  the  junction  of  the  middle  and  inner  thirds  of  the 
clavicle  to  the  middle  of  the  elbow.  An  incision  two  and  one-half 
inches  long  is  made  through  the  integument  down  to  the  deep  fascia; 
tins  incision  is  placed  midway  between  the  anterior  and  posterior 
borders  of  the  axilla,  along  th.e  edge  of  the  coraco-brachialis  muscle. 
This  incision  penetrates  through  the  skin  and  fat.  With  a  second 
stroke  of  the  knife  the  deep  fascia  is  incised,  and  one  may  then,  with 
the  handle  of  the  knife,  seek  the  white,  shiny  tendon  of  the  latis- 
simus dorsi,  which  is  the  guide  to  the  axillary  vessels  in  this  part 
of  their  course.  When  this  tendon  is  recognized,  it  is  followed  up 
toward  its  attachment  to  the  humerus,  diminishing  the  tension  of 
the  parts  by  flexing  the  arm  somewhat  at  the  elbow,  and  then  the 
vessels  and  nerves  are  readily  located,  the  vein,  which  lies  below  and 
internal  to  the  artery,  being  the  first  structure  encountered. 

The  artery  is  carefully  isolated  for  a  short  distance,  using  blunt 
hooks  to  retract  the  adjacent  structures,  and  the  loose  connective 
tissue  which  immediately  surrounds  the  vessel  is  picked  up  with  a 
toothed  forceps  and  nicked  with  the  point  of  a  knife;  through  the 
small  opening  which  is  thus  made  in  the  connective-tissue  sheath  a 
director  may  be  introduced  between  the  vein  and  the  artery  and 
gradually  worked  around  the  artery,  taking  care  to  keep  close  to  the 
wall  of  the  vessel,  so  as  not  to  include  any  of  the  adjoining  structures 
— one  should  avoid,  especially,  the  musculo-spiral  nerve,  which  is 
located  behind  the  artery,  upon  the  tendon  of  the  latissimus  dorsi. 
A  small  aneurism  needle  is  then  carried  around  the  artery,  a  ligature 
passed  through^ its  eye,  and  the  needle  withdrawn,  thus  leaving  the 
vessel  surrounded  by  the  ligature,  which  is  tied  with  a  single  square 
knot. 

The  Brachial  Artery. — The  linear  guide  to  the  brachial  artery 
is  a  line  drawn  from  the  coracoid  process  to  a  point  upon  the  front 
of  the  elbow,  midway  between  the  condyles,  the  arm  being  abducted 
to  a  right  angle  with  the  trunk.    The  muscular  guide  to  the  artery  is 


718 


UPPER  EXTREMITY. 


the  inner  edge  of  the  mass  of  muscle;,  composed  of  the  biceps  and 
coraco-brachialis. 

The  incision,  two  inches  in  length,  is  made  along  the  inner  bor- 
der of  the  coraco-brachialis,  penetrating  through  the  skin  and  sub- 
cutaneous fat  and  exposing  the  deep  fascia.  At  this  stage,  below 
the  middle  of  the  arm,  the  basilic  vein,  lying  superficial  to  the  deep 
fascia  and  to  the  inner  side  of  the  brachial  artery,  is  met.  In  the 
upper  part  of  the  arm  we  would  not  encounter  the  basilic  vein  until 
after  we  had  cut  through  the  deep  fascia. 

The  deep  fascia  is  now  incised  in  a  direction  corresponding  to 
the  skin  incision,  and  the  bundle  of   structures — which  consists  of 


Fig.  321.— Right  Arm.     A,  incision  for  ligation  of  axillary  artery; 
B,  incision  for  ligation  of  brachial  artery. 


the  artery,  venae  comites,  and  adjoining  nerves  and  which  is  readily 
felt  beneath  the  deep  fascia — ^is  exposed. 

In  the  middle  of  the  arm  we  find  the  median  nerve  lying  upon 
and  crossing  the  artery  from  without  inward;  above  the  middle  of 
the  arm  the  median  nerve  lies  close  to  the  outer  side  of  the  artery; 
below  the  middle  it  lies  along  its  inner  side.  The  ulnar  nerve  is  situ- 
ated upon  the  inner  side  of  the  artery,  getting  farther  away  from  it 
as  it  descends  toward  the  elbow-Joint.  The  loose  connective  tissue 
that  surrounds  the  brachial  artery  may  be  now  picked  up  with-  a 
mouse-toothed  forceps  and  nicked  with  the  point  of  the  knife; 
through  the  small  opening  thus  made  a  director  is  introduced  and 


AMPUTATIONS,  RESECTIONS,  ETC.  719 

gradually  worked  around  the  artery,  which  is  thus  isolated  from  tlie 
adjoining  structures,  avoiding  the  vena3  comites,  which  lie  directly 
upon  it.  A  small  aneurism  needle  is  then  passed  around  the  artery 
through  the  path  made  by  the  director,  and  after  a  ligature  is  car- 
ried through  its  eye  the  needle  is  withdrawn,  leaving  the  artery  sur- 
roun(ied  by  the  ligature,  which  is  tied. 

The  Eadial  Artery.  In  the  Middle  of  the  Forearm. — An  in- 
cision one  and  one-half  inches  long  is  made  between  the  middle  and 
inner  thirds  of  the  forearm,  reaching  through  the  skin  and  fat  down 
to  the  deep  fascia;  the  deep  fascia  is  then  incised  and  the  artery  found 
lying  partly  concealed  by  the  overlapping  edge  of  the  supinator  longus, 
which  is  drawn  aside  with  a  retractor.  The  artery  is  accompanied  by 
vencE  comites,  which  lie  close  upon  it,  and  also  to  its  outer  side  by  the 
radial  nerve,  which  is  a  branch  of  the  musculo-spiral. 

Just  Above  the  Wrist. — Here  the  artery  is  found  beneath  the  deep 
fascia,  lying  between  the  tendons  of  the  supinator  iongus  externally 
and  the  flexor  carpi  radialis  internally.  The  radial  nerve  quits  the 
artery  three  inches  above  the  wrist-joint,  and  is  not  met  with  h;3re. 

The  Ulnar  Artery.  In  the  Middle  of  the  Forearm. — An  in- 
cision one  and  one-half  inches  long  is  made  between  the  middle 
and  inner  thirds  of  the  forearm,  through  the  skin  and  fat  down 
to  the  deep  fascia;  the  deep  fascia  is  then  incised,  and  the  artery 
is  found  lying  beneath  the  edge  of  the  flexor  carpi  ulnaris,  which 
must  be  drawn  inward  to  expose  the  vessel.  The  artery  rests  upon 
the  flexor  profundus  digitorum ;  to  the  outer  side  of  the  artery  is  the 
edge  of  the  flexor  sublimis  digitorum.  The  artery  is  accompanied  by 
venae  comites,  which  lie  in  close  relation  with.  it.  The  ulnar  nerve  is 
found  npon  the  inner  side  of  the  artery. 

Just  Above  the  Wrist. — The  iilnar  arterv-  lies  beneath  the  deep 
fascia,  with  the  tendon  of  the  flexor  carpi  ulnaris  to  its  inner  side  and 
the  tendons  of  the  flexor  sublimis  to  its  outer  side;  the  ulnar  nerve 
lies  close  to  the  inner  side  of  the  vessel  in  this  part  of  its  course. 

AMPUTATIONS,  RESECTIONS,  ETC. 

Surgical  Anatomy  of  the  Hand. — The  hand  is  composed  of  ilie 
carpus,  metacarpus,  and  phalanges.  Each  finger  is  made  up  of  three 
phalanges,  the  thumb  of  two  (see  Fig.  324). 

Phalango-phalaxgeal  Joints.— The  fingers  are  formed  by  the 
phalanges,  which  articulate  with  each  other,  end  to  end.     Upon  the 


730  UPPER  EXTREMITY. 

anterior  aspect  are  found  the  flexor  tendons;  upon  the  posterior  are 
the  extensor  tendons. 

Each  phalango-phalangeal  joint  has  an  anterior  ligament  and  two 
lateral  ligaments^  the  posterior  ligament  being  formed  by  the  spread- 
out  extensor  tendon. 

Flexion  and  extension  are  permitted  in  these  joints.  Flexion 
occurs  by  the  gliding  of  the  distal  phalanx  around  the  head  of  the 
proximal,  and  therefore  when  the  finger  is  flexed  the  joint  is  found 
below  the  angle  of  the  knuckle  at  a  distance  which  corresponds  to  the 
thickness  of  the  end  of  the  proximal  bone. 

Metacaepo-phalakgeal  Joints. — These  joints  are  quite  simi- 
lar to  the  phalango-phalangeal ;  they  are  formed  by  the  articulation  of 
the  heads  of  the  metacarpal  bones  with  the  proximal  ends  of  the 
phalanges.  They  are  provided  with  an  anterior  ligament  and  two 
lateral  ligaments;  the  extensor  tendon  spreads  out  in  the  form  of  a 
broad,  fibrous  sheath  as  it  passes  across  the  posterior  aspect  of  the 
joint,  and  thus  serves  as  a  posterior  ligament,  completely  covering  the 
joint  upon  its  posterior  aspect.  The  anterior  ligaments  are  firmly 
united  with  each  other  (except  that  of  the  thumb),  so  as  to  bind  the 
heads  of  the  metacarpal  bones  firmly  together  into  one  strong,  solid 
row,  which  lends  a  great  element  of  strength  to  the  hand. 

The  lateral  ligaments  are  attached  to'  the  bones,  excentrically,  in 
^uch  a  manner  that,  although  a  considerable  range  of  adduction  and 
abduction  is  allowed  when  the  fingers  are  extended,  this  is  not  per- 
mitted when  they  are  flexed ;  when  flexion  takes  place,  the  lateral  liga- 
ments become  relatively  short,  since  the  points  to  which  they  are  fixed 
become  more  widely  separated.  When  flexion  takes  place  between  the 
phalanx  and  the  head  of  the  metacarpal  bone,  it  is  accomplished  by 
ihe  proximal  end  of  the  phalanx  gliding  around  the  head  of  the  meta- 
-carpal  bone,  and,  therefore,  in  this  position,  the  level  of  the  joint  will 
be  found  at  a  distance  below  the  angle  of  the  knuckle  which  corre- 
sponds to  the  thickness  of  the  head  of  the  metacarpal  bone. 

EXARTICULATION    OF    THE    FiNGER   AT    THE    PhALANGO-PHALAN- 

•GEAL  Joint. — In  amputating  a  portion  of  a  finger  an  effort  should 
be  made  to  use  what  integument  may  be  available,  with  a  view  to  pre- 
serving as  much  of  the  length  of  the  finger  as  possible.  ISTo  doubt, 
where  one  may  choose,  the  best  amputation  is  through  a  joint  and  with 
a  long  anterior  flap;  this  brings  the  suture  line  upon  the  posterior 
aspect  of  the  stump  and  out  of  the  way  of  pressure. 

The  end  of  the  finger  which  is  to  be  amputated  is  seized  by  the 


AMPUTATIONS,  RESECTIONS,  ETC.  731 

operator  with  the  left  hand  and  strongly  flexed,  and  a  transverse  in- 
cision, reaching  down  to  the  bone,  is  then  made  across  its  dorsal  sur- 
face, about  one-half  inch  below  the  point  of  the  knuckle ;  this  incision 
should  not  include  more  than  one-half  of  the  circumference  of  the 
finger.  An  additional  incision  is  then  made  upon  either  side,  extend- 
ing from  the  end  of  the  transverse  incision,  along  the  side  of  the 
finger,  for  a  distance  corresponding  to  the  longth  of  the  proposed  flap, 
and  this  should  also  penetrate  to  the  bone. 

With  the  finger  still  strongly  flexed,  the  joint  is  now  opened 
upon  its  dorsal  aspect,  remembering  that  the  line  of  the  joint  lies 
below  the  point  of  the  knuckle.  After  the  joint  has  been  opened 
the  point  of  the  knife  should  be  passed  in  on  each  side  and  the  lateral 


Fig.  322. — Exarticulation  of  the  Finger  at  the  Phalango-phalangeal  Joint. 
The  arrow  indicates  level  of  the  joint  when  the  finger  is  flexed.  Heavy  line 
indicates  the  long  anterior  flap. 

ligaments  freely  divided,  when  the  joint  surfaces  may  be  separated 
from  each  other.  The  blade  of  the  knife  is  then  introduced  between 
the  joint  surfaces  and  behind  the  bone,  between  the  bone  and  the 
anterior  flap,  and  with  a  sawing  motion  the  anterior  flap  is  cut,  with 
the  edge  of  the  knife  directed  toward  the  bone,  down  to  the  level  of 
the  next  joint,  or  until  a  flap  of  sufficient  length  is  obtained,  when 
it  is  cut  from  within  outward  by  turning  the  edge  of  the  knife  toward 
the  skin.  The  digital  arterial  branch  on  either  side  should  be  tied 
with  catgut.  The  corners  of  the  flap  may  be  rounded  off,  although 
this  is  probably  unnecessary.  The  anterior  flexor  tendons  may  be 
united  by  two  catgut  sutures  to  the  edge  of  the  extensor  tendons,  as 
this  increases  the  probability  of  a  movable,  useful  flnger  stump.  The 
edges  of  the  skin  are  approximated  with  two  to  four  catgut  sutures, 
and  the  operation  is  complete. 

40 


722 


UPPEE  EXTREMITY. 


EXAETICULATION   OF    THE   FlNGEE.  AT    THE   MeTACAEPO-PHALAN- 

GEAL  Joint. — Amputation  through  the  metacarpo-phalangeal  joint 
may  be  done  with  or  without  the  removal  of  the  head  of  the  meta- 
carpal bone.  Eemoval  of  the  head  of  the  metacarpal  bone  allows  the 
adjoining  fingers  to  be  approximated,  thus  diminishing,  somewhat, 
the  apparent  deformity,  but  this  is  accomplished  at  the  expense  of  the 
solidity  and  strength  of  the  hand;  so  that,  in  most  cases,  especially 
in  laboring  people,  the  end  of  the  metacarpal  bone  is  better  not  re- 
moved. 

The  finger  is  seized  and  fiexed  as  in  the  previous  operation,  and 
an  incision  made  upon  the  dorsal  aspect  of  the  hand,  commencing 


Fig.  323. — Exarticulation  of  the  Finger.  A,  incision  for  exarticulation  at 
the  metacarpo-phalangeal  joint;  B,  incision  for  amputation  of  finger  with 
excision  of  the  head  of  the  metacarpal  bone;  0  indicates  long  anterior  flap  in 
exarticulation   through  the   phalango-phalangeal  joint. 


one-half  inch  above  the  point  of  the  knuckle  and  carried  down  as 
far  as  the  level  of  the  web  of  the  finger.  This  incision  should  pene- 
trate to  the  bone,  dividing  the  skin  and  also  the  aponeurotic  expansion 
of  the  extensor  tendon.  At  the  lower  end  of  this  incision,  upon  a 
level  with  the  web  of  the  finger,  a  second  incision  is  carried  around 
the  finger,  cutting  all  the  structures,  including  the  anterior  and  poste- 
rior tendons,  down  to  the  bone. 

A  corner  of  the  flap  is  now  seized,  the  finger  being  drawn  toward 
the  opposite  side,  and  the  flap,  including  the  tendinous  expansion,  is 
stripped  away  from  the  bone  with  the  knife;  this  is  then  done,  in  a 
similar  manner,  with  the  other  remaining  half  of  the  flap. 

Now  strongly  flexing  the  finger,  the  joint,  which  is  located  a 


AMPUTATIONS,  RESECTIONS,  ETC.  723 

good  one-half  inch  below,  tiie  angle  of  the  knuckle,  is  opened  by  in- 
serting the  point  of  the  knife,  and  the  lateral  ligament  on  either  side 
is  then  completely  divided.  In  opening  the  joint  and  dividing  the 
lateral  ligaments  the  knife  may  be  grasped  by  the  blade,  being  thus 
held  short  and  firm.  The  bone  is  readily  dissected  out  of  the  flap,  care 
being  taken  not  to  perforate  the  integument  with  the  point  of  the 
knife. 

The  vessels  are  caught  and  tied,  usually  one  on  each  side  of  the 
flap ;  the  corners  of  the  flap  may  be  rounded  off  and  the  end  of  the 
bone  covered  by  uniting  the  edges  of  the  flap  with  several  interrupted 
catgut  sutures. 

If,  in  addition,  the  distal  end  of  the  metacarpal  bone  is  to  be 
removed,  the  dorsal  incision  should  be  extended  somewhat  farther 
upward,  toward  the  wrist,  and  through  all  the  structures  down  to  the 
bone.  With  the  point  of  the  knife  the  soft  parts  are  then  separated 
from  the  bone,  and  with  a  strong  cutting  forceps  the  bone  is  divided 
about  one  inch  above  its  lower  end,  taking  care  to  cut  the  bone 
straight  across.  The  loose  low^er  end  of  the  bone  is  then  seized  with" 
a  toothed  bone-forceps  and  enucleated,  cutting  with  the  edge  of  the 
knife  applied  close  to  the  bone.  After  the  vessels  have  been  ligated, 
the  edges  of  the  flap  are  united  with  interrupted  catgut  sutures.  If 
the  head  of  the  metacarpal  bone  is  taken  away  it  is  not  necessary  to 
make  the  flap  so  long. 

EXARTICULATION"     OF     TIIE    HaND     AT    THE     CaRPO-METACARFAL 

Articulation. — Applicable  to  cases  of  traumatism  where  the  thumb 
can  be  saved. 

The  hand  which  is  to  be  amputated  is  seized  by  the  operator  and 
an  incision  made  which  crosses  the  palm  of  the  hand,  somewhat 
curved,  with  the  convexity  downward  toward  the  fingers;  it  com- 
mences on  the  radial  border  of  the  hand  near  the  head  of  the  meta- 
carpal bone  of  the  index  finger  and  ends  on  the  ulnar  border  of  the 
hand  near  the  base  of  the  fifth  metacarpal  bone.  The  incision  ex- 
tends through  the  soft  parts,  including  the  integument  and  palmar 
fascia,  down  to  the  flexor  tendons.  This  anterior  flap  is  reflected  up- 
ward to  the  level  of  the  carpo-metacarpal  articulation. 

Upon  the  back  of  the  hand  the  incision  extends  through  the  skin 
only,  and  passes  across  the  hand  somewhat  curved,  with  the  concavity 
downward  toward  the  fingers.  If  the  anterior  flap  is  scant,  the  poste- 
rior may  be  made  correspondingly  longer.  The  extremities  of  this 
posterior  incision  join  with  those  of  the  anterior.    The  flexor  tendons 


724 


UPPER  EXTREMITY. 


on  the  front  of  the  hand  and  the  extensors  on  the  back  of  the  hand 
are  now  divided  transversel}^  down  to  the  bone  with  a  sharp  knife. 
The  hand  is  again  supinated  and  the  carpo-metacarpal  articulation 
opened^  working  from  the  ulnar  side  of  the  hand  toward  the  thumb. 
Care  should  be  taken,  in  exarticulating  the  metacarpal  bone  of  the 
index  finger  from  the  trapezoid,  not  to  injure  the  joint  between  the 
metacarpal  bone  of  the  thumb  and  the  trapezium. 


D 


Fig.  324.— Palmar  Aspect  of  Right 
Hand.  CM,  outline  of  the  palmar  flap 
in  exarticulation  of  the  hand  through 
the  carpo-metacarpal  joint;  Z>,  incision 
for  exarticulation  of  hand  at  the  wrist- 
joint  (Dubrueil),   front  view. 


Fig.  325.  —  Dorsal  Aspect  of  Right 
Hand.  CM,  dorsal  incision  for  exar- 
ticulation of  the  hand  at  the  carpo- 
metacarpal joint;  D,  incision  for  ex- 
articulation at  the  wrist-joint  (Du- 
brueil),   back  view. 


The  branches  of  the  radial  and  ulnar  arteries  must  be  clamped 
and  ligated  before  the  tourniquet  is  removed. 

The  edges  of  the  flaps  are  brought  together  with  interrupted 
catgut  sutures,  the  stump  being  thus  covered  by  the  strong  palmar 
integument,  and  the  suture  line  upon  the  posterior  edge  of  the 
stump  free  from  pressure,  etc. 


AMPUTATIONS,  RESECTIONS,  ETC. 


725 


If  the  condition  of  the  integument  of  the  palm  of  the  liand  is 
such  that  the  longer  flap  cannot  be  taken  from  this  part  of  the 
hand,  then  one  may  get  a  sutliciontly  long  flap  from  the  posterior 
surface,  or  two  flaps  of  equal  length,  one  from  the  anterior  and  one 
from  the  posterior  surface  of  the  hand  may  be  made. 

Surgical  Anatomy  of  the  Wrist-joint. — The  wrist-joint  is  formed 
of  the  first  row  of  the  carpal  bones  in  order,  from  without  inward, 
scaphoid,  semilunar,  and  cuneiform,  and  of  the  lower  extremities  of 
tlie  radius  and  ulna. 

The  three  carpal  bones  are  united  to  each  other,  and  present 


Fig.  326.— Stump  Result  of  Exarticulation  of  the  Hand  at  the 
Carpo-metacarpal  Joint. 


one  continuous  surface,  smooth,  covered  with  articular  cartilage, 
and  convex  from  side  to  side  and  from  before  backward.  The  outer 
extremity  of  this  surface  slopes  downward  to  a  much  lower  level 
tJian  the  inner  extremity. 

The  articular  surface  presented  by  the  lower  ends  of  the  radius 
and  ulna  is  concave  in  order  to  accommodate  the  convex  articular 
surface  of  the  upper  row  of  carpal  bones.  This  radio-ulnar  articular 
surface  is  directed  obliquely  downward  externally,  so  that  the  outer, 
or  radial,  end  is  a  considerable  distance  below  the  level  of  the  inner, 
or  ulnar,  end,  and  is  continuel  into  the  external  styloid  process,  to 
the  tip  of  which  the  external  lateral  ligament  is  attached :  the  inner. 


736  UPPER  EXTREMITY. 

01  ulnar,  side  of  this  radio-ulnar  articular  surface  presents  the  inner 
styloid  process,  prolonged  from  the  lower  end  of  the  ulna.  The  tip 
of  this  process  gives  attachment  to  the  internal  lateral  ligament  of 
the  wrist-joint. 

Of  the  three  carpal  bones,  the  outer  two,  the  scaphoid  and 
semilunar,  correspond  to  and  articulate  with  the  radial  articular 
surface;  the  inner,  the  cuneiform,  corresponds  to  the  ulnar  articular 
surface,  an  interarticular  fibro-cartilage  being  interposed  between 
them. 

There  is  a  broad  anterior  and  a  broad  posterior  ligament,  and 
these,  together  with  the  lateral  ligament  on  either  side,  practically 
form  a  capsular  ligament,  which  is  lined  upon  its  inner  aspect  by  a 
thin,  serous  layer,  the  synovial  membrane  of  the  joint. 

EXARTICULATION     OF     THE    HaND    AT    THE    WeIST- JOINT     (Du- 

BRUEiL. — An  assistant  steadies  the  forearm,  drawing  the  integument 
rather  toward  the  elbow.  The  hand  which  is  to  be  amputated  is 
seized  by  the  operator,  and  commencing  upon  the  front  of  the  wrist, 
between  the  middle  and  outer  thirds,  an  incision  is  made,  which  is 
carried  inward  around  the  inner  border  of  the  wrist,  below  the  level 
of  the  styloid  process,  and  across  the  back  of  the  wrist,  terminating 
at  a  point  between  the  middle  and  outer  thirds  and  directly  opposite 
the  point  where  the  incision  commenced.  This  incision  should  ex- 
tend through  the  skin  and  subcutaneous  fatty  tissue  and  should  be 
placed  well  below  the  level  of  the  wrist-joint;  otherwise,  after  the 
integument  has  retracted,  the  cut  edge  will  be  found  to  be  above 
the  level  of  the  wrist-joint. 

A  tongue-shaped  flap,  with  its  base  corresponding  to  the  radial 
third  of  the  circumference  of  the  wrist,  is  now  marked  out  by  an 
incision  reaching  from  either  end  of  the  circular  incision  described 
above.  This  flap  of  integument  is  taken  from  over  the  metacarpal 
bone  of  the  thumb,  its  lower  extremity  corresponding  to  the  meta- 
carpo-phalangeal  articulation  of  the  thumb  (see  Fig.  324).  This  flap, 
including  the  superficial  fascia  and  fat,  is  dissected  back  to  the  level 
of  the  wrist- joint.  The  wrist- joint  is  then  entered  by  introducing 
the  blade  of  the  knife  into  the  joint  on  its  radial  side,  below  the 
styloid  process,  and  the  hand  severed  from  the  forearm,  thus  com- 
pleting the  exarticulation. 

The  radial  and  ulnar  arteries  are  picked  up  and  ligated,  the 
median  and  ulnar  nerves  seized  and  cut  short,  and  the  ends  of  the 
bones  covered  over  with  the  flap,  which  is  fixed  with  interrupted 


AMPUTATIONS,  RESECTIONS,  ETC.  727 

catgut  sutures.  The  first  stitch  should  unite  the  apex  of  the  tongue- 
shaped  flap  to  the  skin  at  a  point  corresponding  to  the  tip  of  the 
styloid  process  of  the  ulna,  and  the  other  stitches  are  then  placed 
so  as  to  distribute  the  flap  evenly,  should  it  be  found  to  be  a  little 
redundant. 

An  analogous  operation  may  be  done  at  the  wrist-joint,  taking 
the  tongue-shaped  flap  of  integument  from  the  ulnar  side  of  the 
hand. 

One  may  also  exarticulate  at  the  wrist-joint,  using  two  flaps, 
an  anterior  and  a  posterior  flap,  of  equal  length;  or  else  one  long, 
preferably  the  anterior,  and  one  short ;  or  the  circular  method  may  be 
used. 

Amputation  through  the  Forearm.— The  forearm  is  a  good  place 
at  which  to  practice  the  old  musculo-tegumentary  flap  method. 
P]-acticaIIy,  this  method  is  now  almost  entirely  discarded  in  favor 
or  the  skin  flap  or  circular  method.  The  arm  overhangs  the  edge 
of  the  table.  The  hand,  which  is  supinated,  is  supported  by  an 
assistant.  A  long,  sharp  amputating  knife  is  introduced  through 
the  skin  upon  the  outer  side  of  the  forearm,  at  the  level  where  it 
is  intended  to  divide  the  bones,  until  its  point  touches  the  outer 
surface  of  the  radius;  it  is  then  pushed  through  the  soft  parts  upon 
the  front  of  the  forearm,  keeping  close  to  the  anterior  surface  of  the 
bones,  and  emerging  at  a  corresponding  point  upon  the  inner,  or 
ulnar,  side  of  the  forearm.  Now,  with  a  sawing  motion  and  with 
the  edge  of  the  knife  directed  toward  the  radius  and  ulna,  the  ante- 
rior flap,  which  includes  the  integument  and  all  tlic  muscular  tissue, 
is  cut  away  from  the  bones.  If  the  anterior  and  posterior  flaps  are 
to  be  of  equal  length,  each  flap  should  correspond  in  length  to  one- 
half  the  diameter  of  the  limb,  at  the  point  where  the  bones  are  to 
be  divided,  plus  one-third  extra,  which  is  allowed  for  retraction. 
When  the  flap  has  been  cut  to  a  sufficient  length,  the  edge  of  the 
knife  is  turned  toward  the  integument  and  the  flap  cut  square  from 
within  outward. 

The  posterior  flap  is  formed  in  a  similar  manner.  The  point  of 
the  knife  is  again  introduced  upon  the  outer,  or  radial,  side  of  the 
forearm  in  the  upper  angle  of  the  incision  which  marks  the  anterior 
flap,  and  thrust  through  the  forearm  behind  the  bones,  between  them 
and  the  soft  parts,  emerging  at  the  upper  part  of  the  incision  upon 
the  inner,  or  ulnar,  side  of  the  forearm,  and  then,  with  the  edge  of 
the  knife  closely  applied  to  the  bones,  the  posterior  flap  is  cut  equal 


738  UPPER  EXTREMITY. 

in  length  to  the  anterior.  The  flaps  should  be  square,  and  not 
tongue-shaped. 

The  flaps  are  turned  back  and  held  thus  by  the  hands  of  an 
assistant  or  with  sharp  retractors,  or  by  the  operator.  With  a  scalpel 
the  interosseous  membrane  is  cut  through  and  the  bones  cleaned  of 
any  remaining  soft  parts,  in  order  to  make  way  for  the  saw. 

The  heel  of  the  saw  is  placed  upon  one  of  the  bones,  and  by 
drawing  it  backward  firmly  and  steadily  a  groove  is  made,  after  which 
the  bones  can  be  rapidly  severed,  engaging  the  second  bone  after 
the  first  has  been  partly  sawn  through,  and  completing  the  section 
of  both  simultaneously.  No  cloth  retractor  is  necessary,  the  flaps 
being  held  back  by  the  operator's  hand  while  he  saws  through  the 
bones. 

In  the  dead  subject  it  will  be  seen  that  the  muscles  in  the  flap 
protrude  beyond  the  edge  of  the  integument;  this  is  due  to  the  un- 
equal retraction  of  skin  and  muscle,  and  does  not  occur  to  the  same 
degree  in  the  living  subject.  Should  the  ends  of  the  muscles  or  ten- 
dons protrude,  they  may  be  trimmed  off  with  the  scissors. 

The  radial  and  ulnar  arteries  are  sought  for  and  ligated;  also 
the  anterior  and  posterior  interosseous.  These  latter  are  found  close 
to  the  anterior  and  posterior  surfaces,  respectively,  of  the  interos- 
seous membrane.  The  median  and  ulnar  nerves  yhould  be  drawn 
down  and  cut  short.  The  edges  of  the  flap  are  joined  all  around 
with  interrupted  catgut  sutures. 

We  may  amputate  through  the  forearm,  using  skin-flaps,  ante- 
rior and  posterior,  of  equal  length,  or  one  long  and  the  other  short; 
or  we  may  reflect  a  circular  tegumentary  cuff,  in  all  of  these  opera- 
tions, dividing  the  muscles  on  a  level  with  or  just  below  the  point 
at  which  the  bones  are  to  be  divided. 

Surgical  Anatomy  of  the  Elbow-joint. — The  elbow-joint  is  an 
irregular,  rather  complicated  joint,  formed  by  the  lower  end  of  the 
humerus  and  the  upper  end  of  the  radius  and  ulna. 

The  lower  end  of  the  humerus  is  broad  from  side  to  side  and 
flattened  from  before  backward,  and  presents  below  two  partially 
separated,  smooth,  rounded,  articular  surfaces,  the  smaller,  outer 
one  being  for  articulation  with  the  radius,  and  the  broader,  inner 
one  for  articulation  with  the  ulna.  The  plane  of  this  double  artic- 
ular surface  is  oblique  from  without  downward  and  inward,  its  inner 
end  being  on  a  much  lower  level  than  its  outer. 

The  surface  for  articulation  with  the  radius,  the  external,  is  a 


AMPUTATIONS,  RESECTIONS,  ETC.  729 

portion  of  a  sphere,  and  occupies  the  lower  and  anterior  aspect  of 
the  humerus. 

The  surface  with  which  the  ulna  articulates,  the  inner,  is  broad, 
spool-shaped,  and  occupies  not  only  the  anterior  and  inferior,  but 
also  the  posterior,  aspect  of  the  bone.  This  portion  articulates  with 
the  greater  sigmoid  cavity  of  the  ulna. 

Below,  the  joint  is  formed  by  the  upper  end  of  the  radius  ex- 
ternally and  the  upper  end  of  the  ulna  internally.  The  upper  end 
or  head  of  the  radius  presents  a  shallow,  cup-shaped  surface,  covered 
with  cartilage  for  articulation  with  the  radial  part  of  the  articular 
surface  of  the  humerus;  this  surface  is  surrounded  by  a  smooth, 
narrow  margin,  which  rotates  within  the  ring  formed  by  the  lesser 
sigmoid  cavity  of  the  upper  end  of  the  ulna  and  the  orbicular  liga- 
ment. 

The  head  of  the  radius  lies  just  below  the  external  condyle,  and 
may  be  recognized  even  when  the  joint  is  considerably  swollen;  by 
supinating  and  pronating  the  hand  it  may  be  felt  to  rotate  beneath 
ti\e  skin.  The  elbow-joint  is  readily  entered  between  the  head  of 
tlie  radius  and  the  external  condyle. 

The  upper  extremity  of  the  ulna  is  irregular,  and  presents  an 
articular  surface,  the  greater  sigmoid  cavity,  which  is  made  up  of 
the  superior  surface  of  the  upper  end  of  the  ulna  and  the  anterior 
surface  of  the  olecranon  process.  The  olecranon  is  a  strong,  square- 
shaped  process  of  bone  which  projects  upward  from  the  posterior 
part  of  the  upper  end  of  the  ulna.  The  greater  sigmoid  cavity  is 
covered  by  articular  cartilage  and  articulates  with  the  trochlear  sur- 
face of  the  lower  end  of  the  humerus.  The  upped  end  of  the  ulna 
further  presents,  upon  its  outer  edge,  a  smooth  depression,  the  lesser 
sigmoid  cavity,  to  either  end  of  which  the  orbicular  ligament  is 
attached.  Within  the  ring  formed  by  the  orbicular  ligament  and 
the  lesser  sigmoid  cavity  the  upper  end  of  the  radius  rotates  in 
pronation  and  supination. 

Besides  the  parts  entering  directly  into  the  formation  of  the 
elbovz-joint  there  may  be  felt,  internally,  the  internal  epicondvle, 
very  prominent  and  giving  attachment,  upon  its  anterior  aspect,  to 
tile  common  tendon  of  origin  of  the  flexor  muscles  of  the  forearm, 
and,  externally,  the  less  prominent  external  epicondvle,  giving  at- 
tachment, upon  its  posterior  aspect,  to  the  common  tendon  of  the 
extensor  muscles  of  the  forearm.  Behind  may  be  felt  the  prominent 
olecranon  process.     At  its  junction  with  the  ulna  the  olecranon  proc- 


730  UPPER  EXTREMITY. 

ess  is  somewhat  constricted^  and  is  here  often  the  site  of  fracture. 
Its  anterior  surface  enters  into  the  formation  of  the  elbow- joint, 
forming  the  upper  part  of  the  greater  sigmoid  cavity.  Its  posterior 
surface  is  subcutaneous  and  triangular  in  shape,  with  its  apex  below, 
where  it  is  continuous  with  the  posterior  border  of  the  shaft  of  the 
ulna.  To  the  broad,  upper  border  of  the  olecranon  process  is  at- 
tached the  triceps  tendon,  and  around  its  margin  the  posterior  and 
lateral  ligaments  of  the  joint.  The  upper  border^  or  surface,  of  the 
olecranon  process,  when  the  arm  is  extended,  is  on  a  line  drawn  be- 
tween the  two  epicondyles. 

The  elbow- joint  is  provided  practically  with  a  capsular  liga- 
ment, which  is  lined,  upon  its  inner  surface,  by  a  synovial  membrane 
v,'hich  also  dips  into  that  part  of  the  joint  between  the  head  of  the 
radius  and  the  lesser  sigmoid  cavity  of  the  ulna  and  orbicular  liga- 
ment. 

The  ulnar  nerve  lies  in  close  relation  with  the  elbow-joint,  poste- 
riorly, in  a  groove  between  the  internal  epicondyle  and  the  olecranon 
process. 

EXARTICULATIOiSr      OF      THE      FOREARM     AT      THE      ELBOW-JOns^T 

(Double  Circular  Method). — The  arm  overhangs  the  side  of  the 
table,  and  is  steadied  by  an  assistant,  who  draws  the  integument 
somewhat  toward  the  shoulder-joint.  The  operator  grasps  the  limb 
with  the  left  hand,  and  with  a  long  amputating  knife  a  circular  in- 
cision is  made  around  the  forearm,  through  the  skin  and  fat  down 
to  the  deep  fascia.  This  incision  should  be  placed  below  the  level 
of  the  elbow- joint  a  distance  corresponding  to  one-half  the  diameter 
of  the  arm  at  the  elbow-joint,  plus  one-third  extra,  which  is  allowed 
for  shrinkage  of  the  skin.  The  upper  surface  of  the  head  of  the 
radius  marks  the  level  of  the  elbow-joint.  This  tegumentary  flap  is 
dissected  away  from  the  deep  fascia  and  reflected  upward  like  a 
turned-up  cuff  as  far  as  the  level  of  the  elbow-joint.  At  this  level 
the  muscles  are  divided  with  the  long  knife  down  to  the  bone,  and 
the  elbow-joint  then  entered  externally  above  the  head  of  the  radius, 
Anally  passing  in  between  the  ulna  and  the  humerus,  cutting  the 
anterior  and  lateral  ligaments.  The  forearm  then  hangs  suspended 
by  the  attachment  of  the  triceps  tendon,  and,  this  being  cut  close  to 
the  olecranon,  the  exarticulation  is  complete. 

In  this  operation  a  common  fault  is  that  the  muscles,  being  cut 
on  a  level  with  the  elbow- joint,  retract  and  leave  the  end  of  the 
humerus  projecting  into  the  wound.    Even  if  the  muscles  are  divided 


AMPUTATIONS,  RESECTIONS,  ETC.  731 

a  considerable  distance  below  the  level  of  the  joint  and  stripped 
away  from  the  bone  from  a  point  below  the  level  of  the  joint,  it  helps 
but  little,  as,  upon  the  posterior  aspect,  there  are  no  muscles,  nnd 
even  the  tendon  of  the  triceps,  when  cut  close  to  the  olecranon,  lies 
well  above  the  level  of  the  joint;  therefore,  in  most  cases,  it  is  de- 
piiable  to  supplement  this  operation  b)^  resecting  the  lower  articular 
end  of  the  humerus,  which  may  be  readily  done.  As  regards  the 
usefulness  of  the  resulting  stump,  it  matters  little  if  we  make  the 
section  just  above,  instead  of  through,  the  elbow-joint. 

It  is  necessary  to  ligate  the  brachial  artery  and  its  accompanying 
vein  separately.  The  median,  ulnar,  and  musculo-spiral  nerves  are 
drawn  down  and  cut  short.  The  edges  of  the  skin  are  united  from 
side  to  side  with  interrupted  catgut  sutures,  and  a  small  drain  intro- 
duced, which  may  be  removed  after  forty-eight  hours. 

Amputation  of  the  Arm. — Here  the  double  circular  method  is 
preferable.  The  arm,  hanging  over  the  side  of  the  table,  is  grasped 
above,  near  the  shoulder,  by  an  assistant,  who,  at  the  same  time  that 
he  steadies  the  arm,  draws  the  integument  somewhat  toward  the 
slioulder.  With  a  long  amputating  knife  a  circular  incision  is  made, 
which  reaches  through  the  skin  and  superficial  fascia  down  to  ihe 
deep  fascia.  This  incision  should  be  placed  below  the  level  at  which 
the  bone  is  to  be  divided  a  distance  equal  to  one-half  the  diameter 
of  the  arm,  plus  one-third,  which  is  allowed  for  retraction  of  the 
skin. 

The  circular  flap,  which  includes  all  the  fatty  tissue,  but  not  the 
deep  fascia,  is  now  dissected  back  like  a  cuff  to  a  point  one  inch 
below  the  level  at  which  the  bone  is  to  be  divided;  at  this  point 
the  muscles  are  severed  down  to  the  bone  with  one  circular  sweep 
of  the  long  knife. 

With  a  blunt  elevator  or  the  back  of  the  scalpel  the  muscles, 
but  not  the  periosteum,  are  separated  from  the  humerus  for  another 
inch,  and  thus  the  level  is  reached  at  which  the  bone  is  to  be  divided. 
After  the  periosteum  has  been  cut  by  drawing  the  knife  around  the 
bone,  the  heel  of  the  saw  is  applied  and  with  a  firm  backward  move- 
ment a  groove  is  made  in  which  the  saw  may  work,  and  then  the  bone 
is  rapidly  severed. 

While  sawing  the  bone  it  is  imnecessary  to  use  a  cloth  retractor, 
as  the  soft  parts  may  be  held  back  so  as  to  give  the  saw  freedom,  by 
the  hands  of  an  assistant,  or  with  two  sharp  retractors. 

Having  completed  the  amputation,  it  will  be  seen  that  the  nius- 


732 


UPPER  EXTREMITY. 


cles  slightl}^  overhang  the  end  of  the  bone  without  covering  it,  and 
that  the  skin-flap  is  sufficientl}^  long  to  cover  the  whole  stump. 

The  brachial  artery  and   accompanying  veins  are  found  lying 
anterior  and  internal  to  the  bone,  and  should  be  clamped  and  tied; 


Fig.  327. — Right  Arm,  Anterior  Aspect.  A,  outline  of  the  lateral  deltoid 
flap  in  exarticulation  at  the  shoulder-joint;  B,  amputation  through  the  arm; 
1,  incision  through  the  skin;  2,  incision  through  the  muscle;  3,  line  of  division 
through  the  bone;  C,  incision  for  exarticulation  through  the  elbow-joint  (cir- 
cular method). 

the  median  and  ulnar  nerves,  which  are  in  close  proximity  to  the 
brachial  artery,  should  be  ciit  short;  likewise  the  musculo-spiral, 
which  is  found  upon  the  posterior  surface  of  the  humerus.  The  supe- 
rior profunda,  a  branch  of  the  brachial  artery,  which  accompanies  the 


AMPUTATIONS,  RESECTIONS,  ETC.  733 

luupculo-spiral  nerve,  is  also  seized  and  ligated.  The  toiiniiquet  is 
then  removed  and  any  remaining  bleedintr  vessels  clamped  and 
ligated. 

The  edges  of  the  skin  are  united  from  side  to  side,  making  a 
transverse  line,  by  several  interrupted  catgut  sutures;  if  the  wound 
is  clean,  one  may  omit  drainage,  or  a  temporary  drain  may  be  intro- 
duced, and  removed  after  forty-eight  hours. 

The  arm  may  also  be  amputated  with  the  formation  of  musculo- 
tegumentaiy  flaps,  as  described  for  the  forearm,  or,  instead  of  a  cuff 
skin-flap,  one  may  use  lateral  or  antero-posterior  skin-flaps  of  equal 
length,  or  one  long  and  the  other  short. 

Surgical  Anatomy  of  the  Shoulder-joint. — The  shoulder-joint 
consists  of  the  articulation  of  the  upper  end  of  the  humerus  and  the 
glenoid  cavity  of  the  scapula.  The  articular  surface  of  the  upper 
end  of  the  humerus  looks  inward  and  backward  and  is  hemispheroidal 
in  shape;  it  presents  the  arc  of  a  smaller  sphere  from  before  back- 
ward, and  of  a  larger  sphere  from  above  downward;  that  is,  the 
diameter  from  before  backward  .is  shorter  than  that  from  above 
downward. 

The  articular  surface  is  limited  by  the  anatomical  neck,  which 
is  narrow  and  well  marked  above,  but  broad  and  less  well  marked 
below;  the  anatomical  neck  marks  the  junction  of  the  head  of  the 
bone  with  the  shaft. 

Externally  may  be  observed  the  broad,  large  tuberosity  major; 
internally  and  below  the  head  is  the  smaller  tuberosity,  the  tuber- 
osity minor.  To  the  tuberosity  minor  is  attached  the  tendon  of  one 
muscle,  the  subscapularis ;  to  the  tuberosity  major — i.e.,  to  its  upper 
and  posterior  borders — are  attached  the  tendons  of  three  muscles: 
the  supraspinatus,  the  infraspinatus,  and  the  teres  minor,  in  that 
order  from  above  downward. 

The  anterior  border  of  the  greater  tuberosity  forms  the  exter- 
nal border  of  the  bicipital  gi'oove,  the  external,  or  anterior,  bicipital 
ridge;  the  lesser  tuberosity  and  the  ridge  that  is  prolonged  down- 
ward from  it  form  the  inner  border  of  the  bicipital  groove,  the  in- 
ternal, or  posterior,  bicipital  ridge.  Between  the  two  is  the  bicipital 
groove. 

To  the  external  bicipital  ridge  is  attached  the  tendon  of  the 
pectoralis  major;  to  the  internal  bicipital  ridge  are  attached  the 
tendons  of  the  latissimus  dorsi  and  teres  major.  Lying  in  the  groove 
itself,  held  in  place  by  a  process  of  fibrous  tissue,  is  the  long  tendon 


734  UPPER  EXTREMITY. 

of  the  biceps  muscle.  Close  to  the  humerus^  between  the  tendon  of, 
the  pectoralis  major  in  front  and  the  tendons  of  the  latissimus  dorsi 
and  teres  major  behind,  are  the  brachial  vessels  and  accompanying 
nerves,  which  descend  in  a  bunch  from  the  axilla,  partially  overlapped 
by  the  coraco-brachialis  muscle.  The  bicipital  groove  really  forms 
the  outer  wall  of  the  axilla  when  the  arm  hangs  by  the  side. 

©elow  the  tuberosities  is  the  surgical  neck,  so  called  because  it 
is  a  rather  common  site  of  fracture. 

The  glenoid  cavity,  a  depressed  area  upon  the  head  of  the  scap- 
ula, is  much  less  extensive  in  area  than  the  articular  surface  pre- 
sented by  the  humerus;  it  is  shallow,  longer  from  above  downward 
than  from  before  backward,  and  is  connected  with  the  body  of  the 
scapula  by  the  neck. 

The  glenoid  cavity  presents  a  slightly  raised  margin,  to  which 
margin  is  attached  the  glenoid  ligament,  which  serves  to  deepen  the 
cavity. 

Overhanging  the  shoulder- joint  is  the  acromion  process,  the 
extreme  outer  end  of  the  spine  of  tlie  scapula ;  this  process  articulates 
with  the  outer  end  of  the  clavicle,  and  forms  the  prominent  outer 
part  of  the  shoulder-girdle  and  a  protecting  ledge  over  the  shoulder- 
joint. 

In  front  and  internal  to  the  shoulder- joint  the  coracoid  process 
may  even  be  felt,  and  in  thin  subjects  seen;  it  projects  forward  from 
the  upper  border  of  the  scapula,  lying  below  the  outer  end  of  the 
clavicle,  to  the  under  surface  of  which  it  is  connected  by  strong  liga- 
ments. Passing  from  the  coracoid  to  the  acromion  process  is  a  strong 
ligamentous  band,  the  coraco-acromial  ligament.  This  ligament 
passes  over  the  head  of  the  humerus,  across  the  upper  part  of  the 
shoulder- joint,  deepening  the  cavity  in  which  the  head  of  the  humerus 
plays  and  serving  to  add  strength  to  the  joint. 

The  shoulder-joint  is  provided  with  a  capsular  ligament,  which 
is  attached  above  to  the  neck  of  the  scapula  around  the  glenoid 
cavity,  and  below  to  the  anatomical  neck  of  the  humerus.  A  sepa- 
rate fibrous  band,  called  the  coraco-humeral  ligament,  extends  from 
the  coracoid  process  down  to  the  neck  of  the  humerus,  where  it  is 
attached  in  common  with  the  capsular  ligament,  of  which  it  is  really 
a  part. 

The  long  tendon  of  the  biceps  is  attached  to  the  upper  margin 
of  the  glenoid  cavity;  it  passes  across  the  upper  surface  of  the  head 
of  the  humerus,  through  the   shoulder- joint,  and   emerges  through 


AMPUTATIONS,  RESECTIONS,  ETC.  735 

the  anterior  part  of  the  capsule,  and  then  passes  down  the  arm,  being 
lodged  in  the  bicipital  groove.  In  its  course  through  the  shoulder- 
joint  the  long  tendon  of  the  biceps  is  entirely  enveloped  in  a  tubular 
process  of  the  synovial  membrane,  and  thus,  although  it  passes 
through  the  shoulder-joint,  the  tendon  is  at  the  same  time  excluded 
from  it. 

Like  a  hood  or  cushion,  the  deltoid  muscle  covers  and  serves  to 
protect  the  shoulder-joint;  beneath  the  deltoid  there  is  a  bursa, 
which  sometimes  becomes  diseased. 

l>elow  the  acromion  and  beneath  the  deltoid  muscle  the  head  of 
the  humerus  may  be  readily  recognized.  It  may  be  felt  to  rotate 
underneath  the  soft  parts  upon  manipulation.  It  is  responsible  for 
the  rounded  contour  of  the  shoulder;  if  the  head  of  tlie  humerus 
leaves  the  glenoid  cavity,  the  shoulder  presents  a  peculiar  flattened 
appearance,  which  is  very  striking,  and  the  sharp  outer  end  of  the 
acromion  process  becomes  especially  prominent  and  tends  to  direct 
attention  to  the  fact  that  the  head  of  the  humerus  has  been  dis- 
located. 

EXARTICULATION     AT     THE      ShOULDER-JOINT      (SpENCE). — The 

shoulder  should  overhang  the  edge  of  the  table  and  the  arm  should 
be  abducted  a  little  from  the  side  of  the  thorax  and  at  the  same  time 
rotated  somewhat  outward,  so  that  the  great  tuberosity  is  directed 
outward. 

The  incision  is  about  six  inches  long,  and  commences  above,  at 
the  clavicle,  between  the  acromion  and  coracoid  processes,  and  passes 
down  the  front  of  the  arm  as  far  as  the  point  where  the  deltoid  is 
attached  to  the  humerus.  Tliis  incision  is  deep,  penetrating  through 
the  skin,  fascia,  and  muscle  down  into  the  bicipital  groove.  With 
the  long  knife  a  circular  incision  is  then  made  around  the  arm,  on 
a  level  with  the  lower  end  of  the  longitudinal  incision;  this  incision, 
upon  the  inner  aspect  of  the  arm,  should  pass  through  the  integu- 
ment and  superficial  fascia  (subcutaneous  fat)  only,  care  being  taken 
not  to  sever  the  brachial  vessels;  for  the  rest  of  the  circumference 
of  the  arm,  however,  this  circular  incision  penetrates  through  all  the 
soft  parts  to  the  bone. 

The  outer  edge  of  the  wound  is  seized,  and  with  a  scalpel  the 
soft  parts  are  dissected  away  from  the  outer  surface  of  the  humerus, 
the  arm  being  rotated  inward  by  the  assistant,  to  facilitate  this  step 
of  the  operation. 

The  capsular  ligament  being  now  exposed,  the  joint  should  be 


736 


UPPER  EXTREMITY. 


opened;  this  is  done,  not  by  passing  the  blade  of  the  knife  flatwise 
between  the  head  of  the  humerus  and  the  acromion  process,  but  by 
cutting  directly  down  upon  the  upper  surface  of  the  head  of  the  hu- 
merus, from  behind  forward,  as  though  one  would  cut  into  the  head 
of  the  bone.  During  this  step  of  the  operation  the  assistant  may  help 
by  rotating  the  arm  first  inward  and  then  outward.    In  this  way  the 


Fig.  328.— Right  Stioulder,  Anterior  View.  R,  line  of  incision  for  resec- 
tion of  shoulder-joint;  S,  incision  for  exarticulation  at  the  shoulder-joint 
(Spence). 


joint  is  freely  opened,  the  long  tendon  of  the  biceps  being  cut  at  the 
same  time.  The  head  of  the  bone  is  now  turned  out  of  its  socket 
and  drawn  forcibly  outward,  away  from  the  glenoid  cavity;  the  long 
knife  is  introduced  into  the  wound,  behind  the  head  of  the  humerus, 
and  the  soft  parts,  with  the  edge  of  the  knife  applied  close  to  the 
surface  of  the  bone,  are  separated  from  the  inner  aspect  of  the 
humerus  to  a  point  a  little  below  the  level  of  the  circular  incision, 
care  being  taken  not  to  injure  the  brachial  vessels,  which  run  parallel 


A^IPUTATIONS,  RESECTIONS,  ETC.  737 

Avith  the  inner  puiface  of  the  humcni?,  and  which  have  not,  as  yet, 
heen  divided. 

Xow,  with  a  final  stroke  of  the  knife,  the  operation  is  completed 
by  cutting  through  the  soft  parts  upon  the  inner  aspect  of  the  arm 
down  to  the  surface  of  the  bone,  thus  severing  the  vessels  and  nerves. 
Just  before  this  final  cut  which  divides  the  vessels  is  made  an  as- 
sistant grasps  the  mass  of  soft  parts  which  have  been  separated  from 
the  inner  side  of  the  humenis  and  which  include  the  brachial  vessels, 
and  thus  compresses  them  while  they  are  being  cut,  and  continues 
to  hold  them  until  the  operator  can  secure  the  divided  vessels  with 
artery  forceps,  after  which  they  are  tied.  Other  vessels  which  spurt 
are  clamped  and  tied  as  the  operation  progresses. 

The  edges  of  the  skin  may  be  brought  together  with  interrupted 
<?atgut  sutures,  a  drain  emerging  from  the  lower  end  of  the  wound 
and  left  in  place  for  forty-eight  to  seventy-two  hours;  or  the  edges 
of  the  wound  may  be  closed  throughout  and  an  opening  made 
through  the  posterior  part  of  the  flap,  nea'r  the  glenoid  cavity,  and  the 
wound  thus  drained.    This  latter  plan  is  very  satisfactory. 

The  above  is  a  good  method  for  exarticulation  at  the  shoulder- 
joint,  which  may  thus  be  accomplished  with  the  loss  of  but  little 
blood.  Through  the  longitudinal  incision,  which  is  first  made,  the 
joint  may  be  opened  and  freely  explored  and  drained,  or  the  joint 
may  be  excised;  this  is  a  great  advantage,  as  we  are  often  in  doubt 
as  to  the  necessity  of  exarticulation  until  after  the  joint  has  been 
opened  and  inspected. 

Exarticulation  at  the  Shoulder-joixt  vs^ith  an  Es:march 
Bandage  Applied. — The  shoulder  overhanging  the  side  of  the  table 
and  the  arm  somewhat  abducted,  an  Esmarch  bandage  or  rubber  tube 
is  applied  tightly  about  the  axilla,  passing  around  the  shoulder  over  the 
outer  part  of  the  clavicle.  With  a  long  knife  a  circular  incision  is  then 
made  tlirough  the  integument  and  fat  down  to  the  deep  fascia. 
This  incision  should  be  placed  just  above  the  insertion  of  the  deltoid 
muscle.  The  integument,  which  retracts  at  once,  is  drawn  toward 
the  shoulder  by  an  assistant,  and  the  muscles,  vessels,  etc.,  divided 
by  a  second  circular  sweep  of  the  long  knife  down  to  the  bone  as 
high  up  as  the  retracted  integument  permits;  the  bone  is  then  sawn 
through  at  this  level.  The  brachial  artery  and  accompanying  veins 
are  now  clamped  and  tied :  also  the  superior  profunda,  which  is  found 
npon  the  back  side  of  the  humeriis  in  company  with  the  musculo- 
spiral  nerve. 

47 


738 


UPPER  EXTREMITY. 


After  these  vessels  have  heen  tied  the  Esmarch  bandage  is  re- 
moved and  any  further  spurting  vessels  ligated. 

A  second  incision  is  now  made  from  the  acromion  process  down 
upon  the  front  of  the  stump  of  the  humerus  and  penetrating  to  the 
bone.     The  soft  parts  are  then  cut  awa}^  from  the  outer  surface  of 


Fig. 


329.— Right  Shoulder,  Posterior  View.     Outline  of  the  lateral  deltoid 
flap   for   exarticulation    at    the    shoulder-joint. 


the  stump  of  the  humerus,  _  tying  vessels  as  they  are  cut,  and  the 
joint  opened  by  incising  the  capsule  from  behind  forward,  including 
the  tendon  of  the  biceps;  the  head  of  the  bone  is  then  turned  out 
of  its  socket,  and  while  it  is  drawn  forcibly  outward,  away  from 
the  glenoid  cavity,  the  soft  parts  upon  its  inner  side  are  stripped 
away  from  the  bone  and  the  operation  thus  completed.     But  little 


AMPUTATIONS,  RESECTIONS,  ETC. 


739 


blood  is  lost.     The  wound  may  be  treated  as  in  the  preceding  oper- 
ation. 

After  the  circular  incision  has  been  made  lhrou<ili  the  soft  parts, 
including  the  muscles,  brachial  vessels,  etc.,  down  to  the  bone,  and 
while  the  tourniquet  is  still  applied  and  without  sawing  through  the 
bone,  one  may  ligate  the  vessels  and  then,  after  removing  the  tourni- 
quet, proceed  to  complete  tlie  operation  by  turning  tlie  head  of  tlie 


Fig.  330.— Left  Shoulder,  Side  View.     Outline  of  the  lateral  deltoid 
flap  for  exarticulation  at  the  shoulder-joint. 


bone  out  of  its  socket  and  stripping  the  soft  parts  away  from 
the  upper  part  of  the  bone  through  the  longitudinal  incision  as  de- 
scribed above.  This  would  save  sawing  through  the  shaft  of  the 
humerus. 

Exarticulation  at  the  Shoulder-joint  with  the  Forma- 
tion OF  A  Lateral  Deltoid  Flap. — The  position  of  the  patient  is  the 
same  as  in  the  previous  operation,  the  shoulder  overhanging  the  edge 
of  the  table.    A  large  musculo-tegiimentary  flap,  U-shaped  and  corre- 


740  UPPER  EXTREMITY. 

sponding  to  the  deltoid  muscle,  is  taken  from  the  outer  aspect  of 
the  arm.  The  incision  commences  anteriorly,  just  external  to  the 
coracoid  process,  and  passes  down  upon  the  front  of  the  arm  to  a 
point  a  short  distance  above  the  insertion  of  the  deltoid  muscle, 
whence  the  incision  is  carried  baclnvard  across  the  outer  aspect  of 
the  arm  and  then  upward  as  far  as  the  spine  of  the  scapula  to  a  point 
just  posterior  to  the  acromion  process;  this  incision  reaches  to  the 
bone  throughout  its  whole  course.  In  dividing  the  muscles  the 
knife  should  be  directed  rather  obliquelj'-,  in  order  that  the  edge  of 
the  musculo-tegumentary  flap  may  be  beveled  at  the  expense  of  the 
deeper  structures  so  that  the  muscles  will  not  protrude  beyond  the 
edges  of  the  skin,  which  retracts  considerably  when  it  is  cut.  Care 
should  be  taken  that  this  flap  is  not  tongue-shaped. 

This  outer  deltoid  flap  is  seized  with  the  fingers  and  dissected 
away  from  the  surface  of  the  bone  and  reflected  up  over  the  shoulder. 
The  spurting  branches  of  the  circumflex  artery  are  seized  with  forceps 
and  tied.  The  capsule  of  the  joint  being  now  exposed,  the  joint  may 
be  opened  by  cutting  through  the  capsule,  from  before  baclovard,  with 
the  edge  of  the  knife  applied  directly  against  the  upper  surface  of  the 
head  of  the  bone,  the  long  tendon  of  the  biceps  being  cut  at  the  same 
time.  The  arm  is  rotated  outward,  and  the  attachment  of  the  sub- 
scapularis  cut  from  the  lesser  trochanter;  then  rotating  inward,  the 
tendons  which  are  attached  to  the  upper  and  j)osterior  border  of  the 
greater  trochanter  are  divided,  when  the  head  of  the  bone  drops  away 
from  the  glenoid  cavity. 

The  joint  being  thus  widely  open,  the  upper  end  of  the  humerus 
is  dragged  outward  away  from  the  glenoid  cavit}^,  and  with  a  long 
Ivnife  the  soft  parts,  attached  to  its  inner  aspect,  are  cut  away  from 
the  bone,  the  edge  of  the  knife  being  held  close  against  the  surface 
of  the  bone,  in  order  to  avoid  injuring  the  brachial  vessels,  which  run 
parallel  with  and  close  to  the  inner  surface  of  the  humerus.  After 
the  soft  parts  have  been  thus  separated  from  the  inner  aspect  of  the 
humerus  to  a  point  about  one  inch  below  the  anterior  fold  of  the  axilla, 
the  edge  of  the  knife  is  turned  inward,  and  with  a  final  stroke  a  short 
inner  flap  is  cut,  dividing  the  vessels  at  the  same  time.  Just  before 
this  final  cut,  which  divides  the  vessels,  is  made,  an  assistant  grasps 
the  mass  of  soft  parts,  which  includes  the  brachial-  vessels,  and  com- 
presses them  until  the  operator  can  secure  the  ends  of  the  severed 
artery  and  accompanying  veins;  these  are  then  ligated  and  the  nerves 
drawn  down  and  cut  short. 


AMPUTATIONS,  RESECTIONS,  ETC. 


741 


Fig.  331.— Left  Arm,  Posterior  View.  E,  incision  for  resection  of  elbow- 
joint;  C,  cuneiform;  M,  os  magnum;  S,  scaphoid;  8L,  semilunar;  T,  trape- 
zium;   TD,    trapezoid;    V,    unciform;    W,    incision    for    resection    of    wrist-joint. 


743 


UPPER  EXTREMITY. 


The  wound  is  closed  with  interrupted  catgut  sutures,  a  drainage 
tube  which  reaches  to  the  glenoid  cavity  being  left  protruding  through 
the  posterior  part  of  the  wound. 


Fig.  332.— Resection  of  Wrist-joint.  AL,  annular  ligament  split  to  show 
the  tendons  of  extensor  secundi  (EX.S)  and  extensor  carpi  radialis  brevior 
{EX.C.B.B.);  EX. I.,  tendon  of  extensor  indicis. 


Eesections.  Weist-joint. — A  tourniquet  is  applied  above  the 
elbow,  in  order  that  the  operation  may  be  bloodless.  A  dorsal  incision 
is  made,  commencing  below,  at  the  middle  of  the  ulnar  border  of  the 
metacarpal  bone  of  the  index  finger,  and  this  is  continued  upward, 


AMPUTATIONS,  RESECTIONS,  ETC.  743 

over  the  middle  of  the  posterior  surface  of  the  radius,  to  a  point  one 
inch  above  the  level  of  the  wrist-joint.  This  incision  passes  through 
the  skin  and  fat  and  runs  parallel  with  the  outer  border  of  the  extensor 
tendon  of  the  index  finger,  the  extensor  indicis. 

This  incision  is  then  gradually  deepened  ?tep  by  step,  and  in  its 
lower  part  one  should  avoid  opening  the  sheath  of  the  extensor  in- 
dicis; in  the  upper  part  of  the  incision,  nearer  to  the  wrist-Joint,  the 
tendon  of  the  extensor  carpi  radialis  brevier,  which  is  attached  to  the 
base  of  the  third  metacarpal  (that  of  middle  finger),  and  the  tendon 
of  the  extensor  secundi  are  exposed.  We  keep  to  the  inner,  ulnar, 
side  of  these  tendons,  drawing  them  toward  the  outer,  radial,  side  of 
the  wound  with  a  blunt  hook,  and  thus  avoid  cutting  them.  The 
wrist-joint  is  then  entered  by  cutting  through  its  posterior  ligament, 
between  the  tendons  of  the  extensor  indicis  and  the  extensor  secundi. 
With  blunt  retractors  the  tendons  of  the  extensor  indicis  and  ex- 
tensor communis  are  drawn  toward  the  ulnar  border  of  the  hand, 
and  the  tendons  of  the  extensor  secundi  and  extensor  carpi  radialis 
brevior  toward  the  radial  border.  Above  the  joint  the  incision  pene- 
trates to  the  surface  of  the  radius  between  the  bunch  of  tendons 
(extensor  communis  digitorum  and  extensor  indicis),  to  the  ulnar 
side,  and  the  extensor  secundi,  to  the  radial  side.  The  edges  of  the 
wound,  including  the  tendons,  being  well  retracted,  an  elevator  is 
introduced  and  all  the  soft  parts  separated  from  the  bones,  working 
as  close  as  possible  to  the  surface  of  the  bone.  It  may  be  necessary 
to  partially  separate  the  attachment  of  the  tendon  of  the  extensor 
carpi  radialis  brevior  from  the  base  of  the  third  metacarpal.  This 
is  accomplished  with  the  elevator  or  by  chipping  away  a  thin  sliver 
of  the  bone  with  a  chisel;  the  tendon  should  not  be  divided  with 
the  knife. 

After  the  carpal  bones  have  been  freely  exposed  the  wrist  is  flexed 
and  the  first  row  is  removed,  commencing  with  the  scaphoid,  then  the 
semilunar, — which  adjoins  it, — and  finally  the  cuneiform.  The  pisi- 
fonn,  which  articulates  with  the  anterior  surface  of  the  cuneiform 
and  to  which  the  tendon  of  the  flexor  carpi  ulnaris  is  attached,  is 
allowed  to  remain  unless  it  is  diseased. 

With  the  wrist  still  flexed,  thus  giving  better  access  to  the  carpus, 
the  second  row  of  carpal  bones  is  now  excised,  commencing  with  the 
OS  magnum,  which  is  easily  recognized  by  its  prominent  rounded  head. 
This  bone  is  seized  with  a  small  lion-tooth  forceps,  isolated,  and  re- 
moved.   Then  the  trapezoid  lying  to  the  outer  side  of  the  os  magnum 


744  UPPER  EXTREMITY. 

and  articiilating  with  the  metacarpal  bone  of  the  index  finger;  after 
this,  the  uncif onn  is  seized  with  the  forceps  and  removed ;  the  trape- 
zium, which  articulates  Math  the  metacarpal  bone  of  the  thumb,  is 
allowed  to  remain,  if  its  condition  permits,  as  its  removal  interferes 
much  with  the  function  of  the  thumb. 

It  is  not  always  necessary  to  remove  all  the  bones  of  the  carpus ; 
when  diseased,  they  may  often  be  readily  enucleated  with  a  sharp 
spoon ;  at  other  times  the  ligamentous  bands  which  join  the  bones  to 
each  other  and  to  the  bases  of  the  metacarpal  bones  must  be  cut  before 
they  can  be  enucleated,  and-  in  doing  this  one  should  be  careful  that 
the  point  of  the  knife  does  not  wound  the  structures  in  the  palm  of 
the  hand.  There  ma}^  be  some  difficulty  in  removing  the  scaphoid. 
In  excising  this  bone,  and  also  the  trapezium,  one  should  remember 
that  the  radial  artery  lies  in  close  proximity  to  their  posterior  surfaces. 
Although  this  vessel  is  usually  separated  from  the  bones  when  tlie  soft 
parts  are  detached  with  the  elevator,  and  is  therefore  not  endan- 
gered, yet  one  should  look  out  for  the  point  of  his  knife. 

The  removal  of  the  unciform  is  rather  difficult,  owing  to  the 
irregularity  of  its  hook-like  process  and  its  muscular  attachments.  It 
may  be  seized  with  a  toothed  bone-forceps,  and,  by  twisting  it  and  at 
the  same  time  cutting  with  the  edge  of  the  knife  close  to  the  bone,  it 
may  be  removed. 

If  the  ends  of  the  radius  and  ulna  are  to  be  removed,  the  soft 
parts,  including  the  tendons,  are  separated  from  the  posterior  surface 
of  the  bones  with  the  periosteum  elevator;  the  lateral  ligaments  are 
also  detached  from  the  bones,  preferably  with  the  periosteum  elevator 
rather  than  with  the  knife,  taking  care  to  avoid  the  radial  artery  as 
it  winds  around  the  outer  side  of  the  wrist.  The  lower  ends  of  the 
bones  are  then  forced  well  out  of  the  wound  and  the  soft  parts  sepa- 
rated from  their  anterior  surfaces,  working  close  to  the  bone  or  sub- 
peri  osteall)^,  and  finally  the  ends  of  the  bones  are  sawn  off.  One 
should  avoid  the  ulnar  artery  and  nerve,  anteriorly,  toward  the  ulnar 
side.    The  tourniquet  may  now  be  removed. 

There  are  usually  no  vessels  to  tie,  none  of  importance  being 
cut.  The  hand  is  placed  upon  a  straight  anterior  splint  and  the  wound 
partly  closed  by  interrupted  sutures  and  packed  with  iodoform  gauze. 

Elbow- JOINT  (Langenbeck). — A  tourniquet  is  placed  about  the 
upper  part  of  the  arm.    The  operation  should  be  done  subperiosteally 

The  arm,  with  the  elbow  flexed,  is  thrown  across  the  patient's 
chest  and  steadied  by  an  assistant;  the  operator  usually  stands  on 


AMPUTATIONS,  RESECTIONS,  ETC.  745 

same  side  as  the  diseased  joint,  although  at  times  it  is  convenient  to 
change  to  the  other  side.  An  incision,  about  four  inches  long,  is 
made  upon  the  posterior  aspect  of  the  joint.  This  incision  commences 
about  two  inches  above  the  upper  border  of  the  olecranon  process  and 
is  continued  downward  upon  tiie  posterior  triangular  surface  of  the 
olecranon  and  ulna,  passing,  not  through  the  middle  of  this  surface, 
but  a  little  to  the  inner  side  of  the  middle  line  and  ending  on  its 
inner  border  (see  Fig.  331).  This  incision  should  be  made  with  a 
heavy  resection  knife,  and  throughout  its  whole  length  should  pene- 
trate through  all  the  soft  parts,  including  the  periosteum,  down  to 
the  bone.  The  upper  part  of  this  incision  splits  the  tendon  of  the 
triceps  lengthwise  right  do^vn  to  its  attachment  to  the  upper  border 
of  the  olecranon,  and  passes  through  the  posterior  ligament  of  tlie 
joint  to  the  surface  of  the  humerus.  The  lower  part  of  the  incision, 
corresponding  to  the  posterior  surface  of  the  olecranon,  passes  through 
the  periosteum  to  the  bone. 

Sharp  retractors  are  introduced  into  the  upper  part  of  the  wound, 
and  the  attachment  of  the  triceps  tendon  is  chiseled  away  from  the 
upper  border,  surface  of  the  olecranon  process  on  either  side,  taking 
a  very  thin  shell  of  bone  with  it;  this  separation  may  also  be  accom- 
plished with  the  knife,  cutting  close  to  the  bone,  but  the  subcortical 
separation  with  the  chisel  is  preferable. 

The  periosteum  elevator  is  now  used  to  separate  the  soft  parts, 
including  the  periosteum,  from  the  posterior  surface  and  sides  of 
the  olecranon  process  and  the  adjoining  upper  part  of  the  ulna  and 
lower  end  of  the  humerus,  working  first  inward  toward  the  inner 
condyle  and  keeping  close  to  the  bone,  as  this  mass  of  soft  parts 
includes  the  ulnar  nerve,  which  is  lodged  in  the  groove  between  the 
inner  condyle  and  the  olecranon ;  if  we  work  subperiosteally,  or  very 
close  to  the  surface  of  the  bone,  the  ulnar  nerve  is  not  seen  and  not 
endangered.  To  retract  this  mass  of  soft  parts  as  it  is  detached  from 
the  bone,  one  should  use  a  blunt-pronged  retractor.  The  separation 
of  the  soft  parts  is  continued  inward  and  around  the  inner  epicon- 
dyle.  In  separating  the  soft  parts  from  the  inner  cpicondyle  one 
should  use  the  chisel  rather  than  the  knife,  since  the  tendon  com- 
mon to  the  superficial  flexor  muscles  is  attached  here,  and  it  would 
be  disadvantageous  to  cut  it.  In  a  similar  manner  the  soft  parts, 
including  the  periosteum,  are  detached  from  the  outer  side  of  the 
olecranon,  continuing  outward  until  the  external  epicondyle  is  de- 
nuded.    To  the  external  epicondyle  is  attached  the  tendon  common 


746  UPPER  EXTREMITY. 

to  the  superficial  extensors,  and  tlierefore  one  sliould  avoid  using 
tlie  knife  here. 

Tlie  separation  of  the  soft  parts  can  be  accomplished  almost 
entirely  with  the  elevator,  if  necessary  using  considerable  force  with 
the  sharp  edge  of  the  elevator  applied  directly  upon  the  bare  surface 
of  the  bone;  but  it  may  be  necessary  here  and  there  to  help  one's 
self  with  the  chisel  and  occasional  snips  with  the  knife.  Upon  the 
posterior  surface  of  the  olecranon  the  knife  may  be  used  a  little 
more  freely,  as  here  the  periosteum  is  thick  and  fibrous,  being  rein- 
forced by  the  triceps  tendon,  and  is  almost  impossible  to  separate 
with  the  elevator. 

After  having  denuded  the  whole  of  the  olecranon  process  and 
the  contiguous  portions  of  the  humerus,  ulna,  and  radius  out  beyond 
the  epicondyles,  the  elbow  is  flexed  and  the  lower  end  of  the  humerus 
forced  out  of  the  wound,  cutting  away  any  remaining  restricting 
bands.  The  soft  parts  about  the  anterior  aspect  of  the  lower  end 
of  the  humerus  are  then  quickly  separated  with  the  elevator  and  the 
articular  end  of  the  bone  sawn  off.  The  section  should  be  made 
through  a  plane  parallel  with  the  articular  surface.  Then,  in  a  like 
manner,  the  upper  end  of  the  radius  and  ulna  are  stripped  of  soft 
parts  and  sawn  off.  The  diseased  synovial  membrane  may  now  be 
completely  excised  with  toothed  forceps  and  blunt-pointed,  curved 
scissors.  One  should  avoid  injuring  the  structures  in  front  of  the 
joint,  brachial  avieij,  etc.,  with  the  point  of  the  knife.  After  the 
resection  has  been  completed  the  tourniquet  may  be  removed.  As  a 
rule,  there  are  no  vessels  to  tie.  The  incision  is  closed,  except  for 
a  part  of  its  length,  which  is  left  open  for  drainage,  and  the  arm  put 
up  in  a  position  of  almost  complete  extension  in  a  splint  or  plaster 
of  Paris  with  a  big  wad  of  dressings. 

After  two  weeks  the  arm  may  be  gradually  or  at  once  flexed  to 
nearly  a  right  angle,  which  is  the  best  position  for  ankylosis.  Occa- 
sionally we  get  some  motion. 

Shoulder-joint  (  Subpeeiosteal  Method  of  Ollier  and 
Hueter). — The  arm  lies  at  the  side,  slightly  abducted  and  rotated 
outward,  so  that  the  greater  tuberosity'  looks  outward.  An  incision  is 
made  which  commences  above,  to  the  outer  side  of  the  coracoid 
process,  and  j)asses  downward,  upon  the  front  of  the  arm,  for  a  dis- 
tance of  flve  inches;  this  incision,  throughout  its  whole  length,  is 
carried  deep  to  the  bone  (see  Fig.  338).  When  the  edges  of  the  wound 
are  held  apart  with  blunt-pronged  retractors,  the  long  tendon  of  the 


AMPUTATIONS,  RESECTIONS,  ETC.  747 

biceps,  as  it  lies  in  the  bicipital  groove  betweea  the  two  tuberosities, 
is  exposed.  This  tendon  emerges  from  within  the  joint  beneath  the 
lower  border  of  the  capsule. 

This  incision  above,  to  the  outer  side  of  the  coracoid  process, 
should  extend  as  high  as  the  clavicle,  in  order  to  allow  easy  access 
to  the  capsule  and  to  the  head  of  the  humerus. 

A  director  is  now  introduced  alongside  of  the  long  biceps  tendon, 
beneath  the  lower  border  of  the  capsule,  and  well  up  into  the  joint, 
and  upon  this  the  capsule  is  divided  as  far  upward  as  the  upper 
border  of  the  glenoid  cavity;  in  this  way  the  capsule  is  split  longi- 
tudinally throughout  its  entire  length  (the  coraco-humeral  ligament, 
which  is  a  part  of  the  capsule,  is  also  divided  in  this  cut)  and  the 
joint  is  thus  freely  opened  upon  its  anterior  aspect. 

The  tendon  of  the  biceps  is  now  lifted  out  of  its  groove  and 
drawn  outward  with  a  blunt  hook,  and  the  periosteum  incised  in  the 
upper  part  of  the  floor  of  the  bicipital  gi-oove,  between  the  two 
tuberosities;  an  elevator,  with  a  sharp  edge,  is  then  introduced  into 
the  incision  in  the  periosteum,  and  this,  together  with  the  attach- 
ment of  the  capsule,  is  separated  from  the  inner  side  of  the  neck  of 
the  bone.  The  tendon  of  the  subscapularis  is  very  intimately  at- 
tached to  the  lesser  tuberosity,  and  in  order  to  separate  this  it  may 
be  necessary  to  use  the  knife  to  some  extent,  cutting  close  upon  the 
surface  of  the  bone,  or,  what  is  preferable,  one  may,  with  the  chisel, 
chip  off  a  thin  layer  of  the  cortex,  carrying  the  attached  tendon  with 
it. 

In  separating  the  capsule  from  its  attachment  around  the  neck 
of  the  bone  it  will  be  necessary,  here  and  there,  to  use  the  knife, 
cutting  with  its  edge  applied  close  to  the  surface  of  the  bone. 

After  the  parts  on  the  inner  aspect  of  the  bone  have  been  thus 
separated,  and  while  the  arm  is  rotated  inward  and  the  long  tendon 
of  the  biceps  hooked  over  toward  the  inner  side,  the  periosteum, 
together  with  the  attachment  of  the  capsule,  is  separated  from  the 
outer  side  of  the  bone;  this  is  accomplished  chiefly  with  the  peri- 
osteum elevator,  with  occasional  snips  with  the  knife.  The  tendons 
attached  to  the  upper  and  posterior  borders  of  the  greater  tuberosity 
are  intimately  united  with  the  bone,  and,  if  they  cannot  be  separated 
vrith  the  periosteum  elevator,  one  may  use  the  chisel,  as  on  the  inner 
side,  removing  a  thin  shell  of  the  cortex  along  with  the  tendon 
attachments.  During  this  part  of  the  operation  the  arm  is  rotated 
more  and  more  inward. 


748  UPPER  EXTREMITY. 

After  the  upper  end  of  the  bone  has  been  thoroughly  isolated 
we  find  it  lying  in  a  sac,  formed  above  by  the  detached  capsule,  which 
is  continuous  below  with  the  periosteum  and  tendons  that  have  been 
separated  from  the  bone. 

The  head  of  the  bone  is  now  thrown  out  of  this  sac  and  out  of 
the  incision,  and  may  be  sawn  off  with  the  flat  saw,  protecting  the 
neighboring  soft  parts,  or  the  chain  or  G-igli  saw  may  be  used,  or  it 
may  be  knocked  off  with  a  broad  chisel. 

After  the  head  of  the  bone  has  been  removed,  the  interior  of 
the  joint  becomes  accessible,  and  one  may  dissect  away  all  the  syn- 
ovial membrane  lining  the  joint  with  toothed  forceps  and  strong, 
blunt-pointed  scissors,  curved  on  the  flat. 

The  glenoid  surface  of  the  scapula,  if  diseased,  may  be  thor- 
oughly curetted  with  the  sharp  spoon,  or  chiseled  or  gouged  out  with 
the  rongeur  bone-forceps.  Usually  no  vessels  of  importance  are  cut; 
any  spurting  points  may  be  caught  and  tied  as  the  operation  pro- 
gresses. 

The  cavity  of  the  joint  should  be  freely  drained  through  the 
lower  part  of  the  incision,  using  a  good-sized  tube.  An  additional 
opening  may  be  made  posteriorly  to  provide  still  better  drainage. 
This  opening  is  made  by  pushing  an  artery  forceps  through  the  mass 
of  deltoid  muscle  from  within  and  then  incising  the  skin  with  the 
knife  upon  this.  We  avoid  making  the  opening  through  the  deltoid 
with  the  knife  in  order  not  to  wound  the  circumflex  nerve  and-  ves- 
sels. The  opening  through  the  muscle  may  be  made  as  large  as 
desired  by  spreading  the  blades  of  the  forceps.  In  closing  the  incis- 
ion interrupted  silkworm-gut  sutures,  which  pass  through  all  the 
structures,  including  the  edges  of  the  split  capsule,  should  be  em- 
ployed. 

If  it  is  intended  to  remove  the  head  of  the  bone  only,  it  is  ]]ot 
necessary  to  separate  the  periosteum  for  more  than  a  short  distance 
upon  the  shaft.  Usually  separation  of  the  capsule  around  the  an- 
atomical neck  and  the  tendons  partially  from  the  greater  and  lesser 
tuberosities  will  give  sufficient  room  to  permit  of  the  excision  of  the 
head  of  the  bone.  Only  when  the  head  of  the  bone  is  to  be  excised 
below  the  trochanters  is  it  necessary  to  separate  the  periosteum  and 
tendons  for  a  greater  distance  below  the  antomical  neck. 

The  operation  as  described  above  differs  from  Langenbeck's  only 
as  regards  the  incision.  The  incision  of  Langenbeck  commences 
above  at  the  acromion  process,  and  is  therefore  more  external;  pass- 


TENDON  SUTURE.  749 

ing  through  the  body  of  the  deltoid,  it  divides  the  circumflex  nerve, 
and  is  therefore  likely  to  be  followed  by  impairment  of  the  function 
of  the  deltoid. 

Tendon  Suture. — Tendons  may  be  found  divided  as  a  complication 
of  a  wound,  or  they  may  be  accidentally  cut  by  the  surgeon  during  the 
course  of  an  operation  about  a  joint;  one  or  several  may  be  severed. 
The  proximal  portion  of  the  tendon,  that  which  is  joined  to  the  muscle, 
may  be  separated  a  considerable  distance  from  the  distal  portion,  owing 
to  the  contraction  of  the  muscle,  and  at  times  considerable  search  may 
be  necessary  to  secure  it,  or  it  may  be  necessary  to  lay  the  sheath  of  the 
tendon  open  for  this  purpose. 

The  ends  should  be  approximated  and  joined  by  a  catgut  suture, 
one  passing  through  the  tendon  proper  being  probably  the  most  satis- 
factory. If  the  flexor  tendons  are  divided,  in  order  to  coapt  the  ends 
and  retain  them  in  position  with  the  minimum  degree  of  tension,  the 
joint  must  be  placed  in  a  position  of  flexion,  and  the  reverse  when  the 
extensor  tendons  are  severed.  Asepsis  is  a  necessary  condition  to 
healing ;  if  the  parts  are  infected,  an  effort  should  be  made  to  render 
them  sterile,  and  under  these  circumstances  drainage  in  addition  is 
probably  advisable  (see  page  35). 

Nerve  Suture. — A  nerve-trunk  may  be  severed,  either  accidentally 
by  the  surgeon  during  the  course  of  an  operation  or  the  condition  may 
be  encountered  as  a  complication  of  an  accidental  wound. 

The  ends  should  be  approximated  and  united  with  one  or  more 
plain  catgut  sutures,  which  may  be  passed  through  the  body  of  the 
nerve  proper.  The  union  may  be  effected  immediately  after  the  oc- 
currence of  the  accident  or  after  the  lapse  of  considerable  time.  If 
immediate,  it  is  simply  necessary  to  coapt  the  ends  and  retain  theni 
in  position  with  one  or  two  sutures ;  if  after  the  lapse  of  a  considerable 
period,  it  will  be  necessary  to  search  for  the  ends  of  the  divided  nerve, 
and,  after  they  are  found,  freshen  them,  before  uniting  them,  end  to 
end,  by  suture.     Plain  catgut  is  preferable  for  the  suture  material. 


PART  X. 

THE   LOWER  EXTREMITY. 


THE  THIGH. 

The  muscles  and  other  structures  of  the  thigh  are  enveloped  by 
the  skin  and  the  superficial  fascia,  which  is  areolar  in  structure  and  in- 
cludes the  subcutaneous  fat.  These  layers  are  loose,  and  movable  upon 
the  deeper  parts.  Beneath  the  fat  (superficial  fascia)  there  is  a 
stroDg,  tense,  fibrous  envelope,  thicker  in  some  parts  than  in  others, 
— the  proper,  or  deep,  fascia, — ^which,  in  the  region  of  the  thigh,  is 
called  the  fascia  lata.  This  layer  is  attached  above  to  Poupart's 
ligament,  the  crest  of  the  pubis,  sacrum,  and  rami  of  the  pubis,  and 
below— about  the  knee-joint,  to  all  the  prominent  bony  points;  it 
confines  the  muscles  and  furnishes  septa,  which  pass  in  between  the 
different  groups  of  muscles  to  be  attached  to  the  ridges  on  the  femur. 
Beneath  the  skin,  in  the  fatty  layer,  ramify  the  various  subcutaneous 
veins  and  nerves,  and  in  the  region  of  the  groin  the  subcutaneous 
arterial  branches  that  are  derived  from  the  femoral. 

The  Gluteal  Region.- — The  gluteal  region  corresponds  to  the 
upper  back  part  of  the  thigh,  and  presents  the  prominence  of  the  but- 
tock. This  is  more  developed  in  some  persons  than  in  others,  espe- 
cially in  females,  and  is  due  chiefly  to  the  cushion  of  fat  beneath  the 
skin. 

After  the  skin  and  fat  have  been  reflected,  the  deep  fascia,  fascia 
lata,  is  exposed.  This  fascia  is  rather  thin  in  this  region,  and  through 
it  the  fasciculi  of  the  gluteus  maximus  muscle  may  be  recognized. 
The  fascia  lata  is  attached  above  to  the  crest  of  the  ilium;  below  it 
is  continuous  with  the  same  layer  of  fascia  upon  the  back  of  the  thigh ; 
internally  it  is  attached  to  the  sacrum  and  coccj^x. 

The  gluteus  maximus  is  a  broad,  thick  muscle ;  it  arises  from  the 
upper,  posterior  portion  of  the  external  surface  of  the  ilium,  from  the 
side  of  the  sacrum  and  coccyx,  from  the  lumbo-sacral  aponeurosis, 
and  from  the  great  sacro-sciatic  ligament.  In  coarse  bundles  its 
fibers  pass  do-\^Tiward  and  outward;  the  upper  fibers  become  tendons, 
and  pass  across  the  great  trochanter  and  are  inserted  into  the  fascia 
lata  upon  the  outer  aspect  of  the  thigh ;  the  lower  fibers  are  attached 
(750) 


THIGH.  751 

to  the  femur  along  tlic  line  wliicli  passes  from  llic  great  trochanter 
downward  to  tlie  linea  aspera. 

The  muscle  should  he  cut  through  at  right  angles  to  the  course 
of  its  fibers  and  reflected,  when  the  btirsjL'  beneath  it,  one  corre- 
sponding to  the  trochanter  major  and  the  other  to  the  tuber  ischii, 
may  be  examined  and  the  parts  which  lie  beneath  the  muscle  exposed 
to  view.  Above  and  in  fi'ont  is  the  posterior  portion  of  the  gluteus 
mcdius,  and  below  this,  but  upon  the  same  plane,  the  pyriformis; 
these  two  muscles  are  separated  from  each  other  by  a  cellular  interval, 
through  which  the  gluteal  vessels  and  nerves  are  seen  to  emerge  from 
within  the  pelvis.  Below  the  pyriformis,  but  still  upon  the  same 
plane,  are  the  two  gemelli  and  the  tendon  of  the  obturator  internus. 
Still  lower  is  found  the  quadratus  femoris,  which  is  really  the  upper 
part  of  the  adductor  magnus  muscle.  These  muscles  are  all  attached 
to  the  femur  at  or  near  the  great  trochanter.  Passing  downward  from 
the  tuberosity  of  the  ischium  are  the  semimembranosus  and  the  semi- 
tendinopus  and  biceps  muscles. 

The  space  which  exists  in  the  skeleton  between  the  lateral  border 
of  the  sacrum  and  coccyx  and  the  margin  of  the  ischium  is  converted 
into  two  foramina,  the  greater  and  lesser  sacro-sciatic  foramina,  by 
the  greater  and  lesser  sacro-sciatic  ligaments.  The  greater  sacro-sciatic 
ligament  is  attached  by  its  broad  base  to  the  margin  of  the  sacrum  and 
coccyx  and  by  its  other  end  to  the  tuberosity  of  the  ischium;  the  pos- 
terior surface  of  the  great  sacro-sciatic  ligament  gives  attachment  to 
some  fibers  of  the  gluteus  maximus  muscle.  The  lesser  sacro-sciatic 
ligament  is  attached  to  the  margin  of  the  sacrum  and  coccyx  and  to 
the  spine  of  the  ischium;  the  lesser  is  situated  upon  a  plane  anterior 
to  the  greater. 

Through  the  greater  sacro-sciatic  foramen  emerge  the  pyriformis 
muscle;  the  gluteal  vessels  and  nerve  which  appear  above  the  pyri- 
formis, between  it  and  the  gluteus  medius ;  the  sciatic  artery  and  great 
sciatic  nerve,  which  appear  below  the  pyriformis,  and  the  internal 
pudic  vessels  and  nerve.  The  internal  pudic  vessels  and  nerve,  after 
emerging  from  the  pelvis  through  the  great  sacro-sciatic  foramen, 
curve  around  the  lesser  sacro-sciatic  ligament,  close  to  the  ischium, 
and  pass  forward  into  the  deep  part  of  the  perineum. 

Stketciiing  the  Sciatic  Nerve. — The  patient  lies  upon  the  ab- 
domen with  a  sandl)ag  under  the  lower  part  of  the  trunk.  An  incision 
three  inches  long  is  made  upon  the  back  of  the  thigh,  the  upper  end 
of  the  incision  corresponding  to  the  middle  of  a  line  drawn  from  the 


752 


LOWER  EXTREMITY. 


tuberosity  of  the  ischium  to  a  point  a  hand's  breadth  below  the 
grejat  trochanter;  this  incision  passes  through  the  skin  and  fat 
down  to  the  deep  fascia;  the  lower  edge  of  the  gluteus  maximus 
is  now  recognized,  and  at  this  point  the  deep  fascia,  fascia  lata, 
is  incised;  through  the  opening  thus  made  in  the  deep  fascia  two 
fingers  are  introduced   and  passed  under  the  edge   of  the   gluteus 


Fig.  333. — Stretching  Sciatic  Nerve.    B,  tendon  of  biceps;   G-M,  lower  edge 
of  gluteus  maximus;   N,   sciatic  nerve. 


maximus,  and  the  sciatic  nerve  hooked  up  and  drawn  out  of  the 
wound.  Three  or  four  fingers  being  now  passed  under  the  nerve, 
it  may  be  stretched  to  the  desired  degree,  pulling  with  a  gradually 
increasing  force  up  to  one  hundred  pounds;  this  may  be  repeated 
once  or  twice;  in  order  to  regulate  the  force  one  may  use  a  scale 
and  hook.     No  vessels  are  met  with,  and  it  will  but  rarely  be  neces- 


THIGH.  753 

?ary  to  apply  any  ligatures;  the  wound  in  the  skin  is  closed  without 
drainage. 

The  Anterior  Femoral  Region. — T^pon  the  anterior  part  of  the 
thigh  just  below  the  inner  end  of  Poupart's  ligament  is  the  saphenous 
opening;  this  is  a  slit-like  opening  in  the  deep  fascia,  fascia  lata, 
through  which  the  internal  saphenous  vein  passes  to  join  the  femoral. 
Its  outer  margin  presents  a  prominent,  curved,  overhanging  edge, 
the  falciform  process.  The  femoral  vessels  are  situated  beneath  the 
iliac  portion  of  the  fascia  lata,  external  and  adjacent  to  this  falciform 
margin,  resting  upon  the  pcctineus  and  ilio-psoas  muscles  (see 
Femoral  Eegion,  Hernia). 

This  falciform  process,  or  mai'gin,  is  continuous  above  with 
Poupart's  ligament,  and  may  be  traced  farther  inward  into  Gimber- 
nat's  ligament;  below  it  curves  inward  and  upward  beneath  the 
saphenous  vein,  and  is  here  continuous  with  that  portion  of  the 
fascia  lata,  pubic  portion,  which  covers  the  surface  of  the  pectineus 
muscle,  being  continued  upward  upon  the  surface  of  this  muscle  and 
under  Poupart's  ligament  as  far  as  the  pectineal  line,  where  it  is 
attached  (see  Figs.  2Go  and  271).  In  the  upper  part  of  the  thigh, 
behind  the  femoral  vessels,  this  fascia  that  covers  the  pectineus  mus- 
cle is  continuous  with  that  which  covers  the  ilio-psoas  muscle,  the 
fascia  iliaca. 

The  saphenous  opening  is  partly  closed  by  a  wad  of  fascia,  which 
is  adherent  around  the  margin  of  the  opening  and  wdiich  is  called 
the  fascia  cribrosa.  The  fascia  cribrosa  is  pierced  by  the  internal 
saphenous  vein,  which  passes  through  the  saphenous  opening  and 
joins  the  femoral  vein  on  its  inner  side. 

The  Ixternal  Saphenous  A^ein  lies  beneath  the  fatty  layer  of 
the  skin;  it  commences  upon  the  dorsum  of  the  foot,  and  passes  up- 
ward in  front  of  the  internal  malleolus,  along  the  inner  side  of  the  leg, 
and  across  the  knee-joint  behind  the  internal  condyle,  immediately 
above  which  it  often  presents  a  pouch-like  dilatation;  it  is  continued 
upward  upon  the  inner,  front  aspect  of  the  thigh,  and  just  below 
Poupart's  ligament  passes  through  the  saphenous  opening  to  join 
the  femoral.  It  receives  many  branches  all  along  its  course.  That 
part  of  the  vein  and  its  tributaries  which  correspond  to  the  leg  and 
to  the  neighborhood  of  the  knee-joint  are  apt  to  become  very  tortu- 
ous, dilated,  and  pouched,  exhil^iting  the  common  conditions  kno^m  as 
'•'varicose  veins."  Just  before  it  enters  the  saphenous  opening  the 
vein  receives  manv  branches  from  the  front  and  inner  side  of  the 


754  LOWER  EXTREMITY. 

thighj  all  radiating  toward  the  saphenous  opening,  and  here  also  it 
receives  the  veins  which  correspond  to  the  subcutaneous  branches 
of  the  femoral  arterj^  The  saphenous  vein  is  accompanied  by  a 
chain  of  Ij^mphatics  which  terminate  in  nodes  located  about  the 
saphenous  opening,  and  these  may  become  enlarged  and  tender  when 
infectious  processes  are  present  below  in  the  integument  of  the  leg 
or  thigh. 

Those  lymphatics  which  are  situated  along  Poupart's  ligament 
in  the  groin  are  usually  enlarged  when  the  external  genitals  are  the 
seat  of  disease. 

In  this  anterior  femoral  region  also,  lying  beneath  the  skin,  are 
found  the  superficial  branches  from  the  femoral  artery.  The  super- 
ficial epigastric  passes  through  the  saphenous  opening  and  upward 
across  Poupart's  ligament  to  ramify  upon  the  lower  abdomen.  The 
superficial  external  pudic  passes  through  the  saphenous  opening  and 
inward  to  supply  the  skin,  etc.,  of  the  external  genitals.  The  super- 
ficial circumflex  iliac  passes  npward  and  outward,  piercing  the  deep 
fascia  external  to  the  sajDhenous  opening  and  runs  parallel  with  and 
below  Poupart^s  ligament,  supplying  the  skin  and  glands  in  this 
region. 

These  vessels  are  usually  cut  in  making  the  incision  for  hernia 
and  in  extirpating  diseased  glands  in  this  region. 

The  Femoral  Aeteey.  Scarpa's  Triangle. — Upon  removing  the 
integument  and  deep  fascia  from  the  upper  anterior  part  of  the  thigh 
we  expose  a  triangular  space,  Scarpa's  triangle.  This  triangle  corre- 
sponds to  the  upper  third  of  the  thigh;  its  base,  which  is  above,  is 
formed  by  Poupart's  ligament;  its  outer  border  by  the  sartorius 
muscle,  and  its  inner  border  by  the  adductor  longus.  The  apex  of 
the  triangle  is  below  where  these  muscles  meet.  The  floor  of  the 
triangle  is  formed,  from  within  outward,  by  the  adductor  longus,  the 
pectineus,  and  the  ilio-psoas. 

Passing  downward  through  this  space,  from  the  middle  of  its 
base — i.e. J  midway  between  the  anterior  superior  spine  of  the  ilium 
and  the  spine  of  the  pubic  bone — to  its  apex,  is  the  femoral  artery 
accompanied  by  the  femoral  vein.  The  femoral  artery  is  the  con- 
tinuation downward  into  the  thigh  of  the  external  iliac,  and  emerges 
from  the  abdomen  underneath  Poupart's  ligament  at  the  point  al- 
ready described.  Toward  the  lower  part  of  Scarpa's  triangle  the 
femoral  artery  is  overlapped  by  the  inner  edge  of  the  sartorius 
muscle. 


'IIIICII. 


755 


Fig.  334.— Section  through  the  Middle  of  the  Right  Thigh.     A.V.,  femoral  artery 
and  vein;   G.,   gracilis  muscle;   R.,   rectus  muscle;  S.y.,   sciatic   nerve. 


756  LOWER  EXTREMITY. 

After  traversing  Scarpa's  triangle  the  femoral  vessels  are  con- 
tinned  downward  along  the  inner  side  of  the  thigh,  lying  heneath 
the  sartorius  mnscle,  qnite  close  to  the  femur  and  inclosed  within 
Hunter's  canal. 

Hunter  s  Canal  is  a  musculo-fibrous  space  corresponding  to  the 
middle  third  of  the  thigh,  lying  close  to  the  inner  side  of  the  femur; 
its  outer  wall  is  formed  by  the  vastus  internus,  which  separates  the 
vessels  from  the  bone;  its  inner  wall  by  the  adductor  longus,  and 
in  the  lower  part  of  the  thigh  by  the  adductor  magnus;  the  space 
between  the  muscles  is  roofed  over  by  a  fibrous  sheet,  which  is  de- 
rived from  the  deep  fascia.  Hunter's  canal  ends  below,  above  the 
internal  condyle,  at  the  foramen  in  the  adductor  magnus  muscle, 
through  which  the  femoral  vessels  pass  into  the  popliteal  space. 

About  two  inches  below  Poupart's  ligament  the  femoral  artery 
gives  off  a  large  branch,  the  profunda  femoris.  This  vessel  arises 
from  the  outer  and  posterior  aspect  of  the  femoral  artery;  at  its 
origin  it  curves  slightly  outward  and  then  passes  behind  the  femoral 
artery  and  vein,  and  dips  into  the  floor  of  Scarpa's  triangle,  passing 
through  the  space  between  the  adductor  longus  and  the  pectineus; 
it  then  descends  in  the  thigh,  resting  upon  the  adductor  magnus 
along  the  inner  side  of  the  femur  and  giving  off  branches  which 
perforate  the  adductor  magnus  to  anastomose  with  branches  upon. 
the  back  of  that  muscle. 

The  femoral  artery  gives  off  other  small  branches  in  Scarpa's 
triangle,  but  they  are  of  little  surgical  importance. 

As  the  femoral  artery  emerges  from  underneath  Poupart's  liga- 
ment it  is  accompanied  by  the  femoral  vein,  which  lies  to  its  inner 
side.  During  the  course  of  the  artery  through  Scarpa's  triangle 
the  vein  gradually  gets  to  lie  behind  the  artery,  and  in  Hunter's 
canal  it  is  located  behind  and  a  little  to  its  outer  side. 

As  the  femoral  vessels  pass  out  through  the  femoral  space,  be- 
neath Poupart's  ligament,  they  are  inclosed  in  a  connective-tissue 
sheath,  which  is  continuous  with  the  subperitoneal  connective  tissue 
of  the  abdomen  and  which  is  closely  adherent  all  around  the  margin 
of  the  femoral  space:  above  to  Poupart's  ligament,  below  to  the 
fascia  which  covers  the  ilio-psoas  and  pectineus  muscles,  and  inter- 
nally to  the  margin  of  Gimbernat's  ligament.  This  femoral  sheath 
is  divided  into  three  distinct  compartments  by  fibrous  septa;  the 
outer  compartment  contains  the  arter}^,  the  middle  one  the  vein; 
the  inner  compartment  contains  a  small  amount  of  connective  tissue 


THIGH.  757 

and  fat,  and  tlirough  it  tlic  Ivinphatics  from  the  tlii<j;h  pass  into  the 
abdomen.  Thi.s  inner  (■oiii])artment  is  continued  but  a  short  dis- 
tance downward  upon  the  inner  side  of  the  femoral  vein ;  it  corre- 
sponds to  the  space  between  tlie  femoral  vein  and  the  outer  edge 
of  Gimbernat's  ligament,  and  forms  the  crui'al  canal,  into  which  the 
gut  descends  in  femoral  hernia. 

As  the  vessels  emerge  from  the  abdomen  under  Poupart's  liga- 
ment they  are  contained  within  their  sheath,  Avhich  is,  in  turn,  par- 
tially covered  anteriorly  by  that  portion  of  the  fascia  lata  which  lies 
external  to  the  falciform  edge  of  the  saphenous  opening;  underneath 
Poupart's  ligament  the  vessels  within  their  sheath  rest  upon  the  ilio- 
psoas and  pcctineus  muscles. 

The  ilio-psoas  muscle  is  covered  over  by  a  layer  of  fascia,  the 
iliac,  which  is  continuous  internally  with  the  fascia  that  covers  the 
pectineus  muscle  (the  pubic  portion  of  the  fascia  lata).  This  layer 
of  fascia,  wliich  covers  the  ilio-psoas  muscle,  is  simply  the  continua- 
tion downward,  under  Poupart's  ligament  into  the  thigh,  of  the  fascia 
iliaca,  which  covers  these  muscles  within  the  abdomen. 

The  Anterior  Crural  Nerve. — At  Poupart's  ligament,  lying 
to  the  outer  side  of  the  femoral  artery  and  imbedded  in  the  substance 
of  the  ilio-psoas  muscle,  is  the  anterior  crural  nerve.  This  nerve  is 
separated  from  the  femoral  artery  by  the  iliac  fascia,  which  invests 
the  ilio-psoas  muscle  and  is  not  seen  in  the  thigh  until  this  layer 
of  fascia  has  been  incised. 

Below  Poupart's  ligament  the  anterior  crural  nerve  divides  into 
cutaneous  and  muscular  branches.  The  internal  or  long  saphenous 
nerve,  the  largest  of  the  cutaneous  branches,  approaches  the  femoral 
artery  as  it  lies  in  Scarpa's  triangle,  and  accompanies  it  down  along 
the  inner  side  of  the  thigh,  through  Hunter's  canal.  At  the  lower 
end  of  the  canal,  where  the  femoral  vessels  pass  through  the  ad- 
ductor foramen  into  the  popliteal  spac«  and  just  above  the  internal 
condyle,  the  nerve  becomes  more  superficial,  lying  beneath  the  sar- 
torius;  below  the  knee-joint  it  l)ecomes  subcutaneous,  and  runs  down 
the  inner  side  of  the  leg  in  company  with  the  internal  saphenous  vein, 
and  supplies  the  skin  of  the  leg. 

Ligation  of  the  Femoral  Artery.  The  Common  Femoral. — 
The  common  femoral  is  sometimes  ligated  as  a  ])ivliininary  to  exartic- 
ulation  of  the  thigh  at  the  hip-joint.  The  vessel  is  ligated  immediately 
below  Poupart's  ligament,  above  the  origin  of  the  profunda  femoris 
branch,  where  it  is  quite  superficial. 


758 


LOWER  EXTREMITY. 


An  incision  about  two  inches  long  is  madC;,  commencing  above, 
at  the  middle  of  Ponpart's  ligament;  i.e.,  at  a  point  midway  between 
the  anterior  superior  iliac  spine  and  the  spine  of  the  pubes.     This 


Fig.  335.— Ligation   of  Femoral   Artery.     CF,    incision  for   ligation   of  common 
femoral;  F,  incision  for  ligation  of  femoral  in  Scarpa's  triangle, 


incision  passes  through  the  skin  and  fat  down  to  the  deep  fascia;,  the 
fascia  lata.  The  pulsation  of  the  artery  may  be  readily  felt  with 
the  finger  in  the  wound. 


THIGH.  759 

Tlie  deep  fascia  is  incised  and  tlie  artery  exposed  by  stripping 
away  its  connective-tissue  sheath.  An  aneurism  needle,  carrying  a 
catgut  ligature,  is  passed  around  the  vessel  from  within  outward, — 
i.e.,  between  the  vein  and  artery, — and  tlicii  withdrawn,  thus  leaving 
the  artery  surrounded  by  the  ligature,  which  is  tied.  The  femoral 
vein,  which  lies  to  the  inner  side  of  the  artery,  can  be  tied  at  the 
same  time,  through  the  same  incision.  The  wound  is  closed  with 
several  interrupted  sutures.  This  procedure  makes  the  exarticula- 
tion  at  the  hip- joint  practically  a  bloodless  operation. 

The  Femoiial  in  Scarpa's  Triangle. — The  femoral  artery  is 
occasionally  ligated  for  aneurism  involving  its  lower  portion  or  its 
continuation,  the  popliteal. 

For  this  purpose  the  ligature  is  usually  applied  in  the  lower 
part  of  Scarpa's  triangle,  about  five  inches  below  Poupart's  ligament, 
and  therefore  below  the  origin  of  its  profunda  femoris  branch.  The 
course  of  the  artery  is  indicated  by  a  line  drawn  from  a  point  above, 
midway  between  the  anterior  superior  spine  of  the  ilium  and  the 
spine  of  the  pubes,  to  the  internal  condyle  below.  The  muscular 
guide  to  the  artery,  in  this  part  of  its  course,  is  the  inner  border  of 
the  sartorius  muscle,  which  slightly  overlaps  the  vessel. 

The  patient  is  placed  upon  the  back,  with  the  leg  rotated  slightly 
outward.  The  incision  is  made  about  three  inches  long,  correspond- 
ing to  the  inner  border  of  the  sartorius  muscle;  it  commences  above, 
about  four  inches  below  Poupart's  ligament.  This  incision  parses 
through  the  skin  and  subcutaneous  fat  and  thi-ough  the  sheath  of 
the  sartorius,  exposing  the  inner  edge  of  this  muscle;  the  muscle  is 
readily  recognized  by  the  oblique  course  of  its  fibers.  In  this  in- 
■cision  some  tributaries  of  the  long  saphenous  vein  are  cut  and  clamped. 
Having  fully  recognized  the  edge  of  the  sartorius  muscle,  this  is 
drawn  outward,  and  the  vessel  may  then  be  located  by  its  pulsation 
beneath  the  deep  fascia;  this  layer  of  deep  fascia  is  incised  along 
the  course  of  the  artery  and  the  vessel  thus  exposed.  In  this  situation 
the  vein  is  found  lying  behind  the  artery  and  still  slightly  to  its 
inner  side ;  the  long  saphenous  nerve  lies  a  short  distance  to  the  outer 
side  of  the  artery.  We  may  see  the  internal  cutaneous  nerve  passing 
obliquely  inward  across  the  sheath  of  the  artery. 

The  loose  connective  tissue,  which  forms  the  sheath  of  the 
artery,  is  now  picked  up  with  a  thumb  forceps  and  nicked  with  the 
point  of  the  knife,  and  through  the  opening  thus  made  a  director  is 
introduced  between   the   artery   and   the   vein,   w^orking   around   the 


760  LOWER  EXTREMITY. 

arter}^,  close  to  its  wall^  from  within  outward.  After  tlie  artery  has 
been  thus  isolated  a  catgut  ligature  is  carried  around  it,  also  from 
within  outward,  in  an  aneurism  needle.  Before  tying  the  ligature 
one  should  again  investigate  to  make  certain  that  the  artery  alone 
is  included,  and  then  tie  a  single  square  knot.  The  incision  is  closed 
with  several  catgut  sutures. 

The  Popliteal  Space. — The  femoral  artery  and  vein,  having  passed 
through  the  opening  in  the  lower  part  of  the  adductor  magniis  muscle, 
enter  the  popliteal  space^  and  are  known  here  as  the  popliteal  artery 
and  vein. 

The  popliteal  space  is  lozenge-shaped  and  situated  behind  the 
knee.  It  is  bounded  above  and  externally  by  the  biceps;  above  and 
internally  by  the  semimembranosus,  semitendinosus,  gracilis,  and 
sartorius,  the  tendons  of  these  muscles  being  known  as  the  outer  and 
inner  hamstrings,  respectively.  Below  and  externally  the  space  is 
bounded  by  the  outer  head  of  the  gastrocnemius,  and  below  and  in- 
ternally by  the  inner  head  of  the  same  muscle.  The  floor  of  the 
space  is  formed,  from  above  downward,  by  the  posterior  surface  of 
the  lower  end  of  the  femur,  the  posterior  ligament  of  the  knee-joint, 
and  the  pop li tens  muscle. 

Passing  from  the  upper  angle,  through  the  space,  to  the  lower 
angle,  where  it  becomes  the  posterior  tibial,  is  the  internal  popliteal 
nerve.  In  the  upper  part  of  the  space,  emerging  from  beneath  the 
biceps  muscle,  is  the  external  popliteal  nerve ;  this  nerve  passes  doAvn- 
ward  and  outward  along  the  inner  edge  of  the  biceps  tendon. 

The  popliteal  artery,  with  its  accompanying  vein,  enters  the  pop- 
liteal space  above,  emerging  from  beneath  the  semimembranosus,  near 
the  upper  angle  of  the  space ;  therefore  in  the  upper  part  of  the  space 
the  artery  lies  to  the  inner  side  of  the  internal  popliteal  nerve ;  about 
the  middle  of  the  space,  however,  the  artery  passes  underneath  the 
nerv^e ;  and  in  the  lower  part  of  the  space  it  is  found  to  the  outer  side 
of  the  nerve. 

The  popliteal  artery  lies  close  to  the  floor  of  the  popliteal  space, 
separated  from  the  posterior  ligament  of  the  knee-joint  by  a  little 
connective  tissue;  the  vein  is  placed  superficial  to  the  artery  and 
rather  to  its  outer  side;  the  internal  popliteal  nerve  lies  superficial 
to  the  vessels,  crossing  them  from  above  downward.  The  popliteal 
artery  gives  off  several  branches,  but  they  are  of  but  little  surgical 
importance. 

The  popliteal  space  is  covered  by  the  skin  and  superficial  fascia 


LEG.  761 

(fat)  and  by  the  deep  fascia,  which  is  stretched  between  the  ham- 
string tendons.  When  tlie  popliteal  artery  roaches  the  lower  part 
of  the  popliteal  space  it  divides  into  two  branches,  tlie  anterior  and 
posterior  tibial. 

It  is  seldom  or  never  necessary  to  tie  the  popliteal ;  for  popliteal 
aneurism  the  ligation  of  the  femoral  is  preferred. 

THE  LEG. 

The  Anterior  Tibial  Artery. — Just  below  the  lower  border  of  the 
popliteus  muscle  the  anterior  tibial  artery  passes  forward,  through 
an  opening  in  the  interosseous  membrane  between  the  tibia  and  the 
fibula,  to  the  front  of  the  leg;  it  then  passes  downward,  lying  upon 
the  front  surface  of  the  interosseous  membrane,  accompanied  by  two 
venae  comites.  one  on  either  side.  In  the  upper  third  of  the  leg  the 
vessel  lies  between  the  tibialis  anticus  on  its  inner  side  and  the 
extensor  longus  pollicis  on  its  outer  side.  I'pon  the  front  of  the 
ankle  the  artery  lies  beneath  the  anterior  annular  ligament,  having 
the  tendon  of  the  extensor  longus  pollicis  on  its  inner  side  and  the 
tendons  of  the  extensor  longus  digitorum  on  its  outer  side.  Upon 
the  front  of  the  ankle  the  tendon  of  the  tibialis  anticus  lies  to  the 
inner  side  of  the  tendon  of  the  extensor  longus  pollicis,  and  the 
perineus  tertius  lies  to  the  outer  side  of  the  tendons  of  the  ex- 
tensor longus  digitorum.  After  the  anterior  tibial  artery  emerges 
from  beneath  the  lower  border  of  the  anterior  annular  ligament, 
it  is  continued  downward  as  the  dorsalis  pedis,  lying  in  the  first 
interosseous  space,  and  giving  off  a  branch  which  pisses  outward 
across  the  tarsus,  and,  lower  down,  one  which  passes  outward  across 
the  heads  of  the  metatarsal  bones.  This  latter  branch,  which  is 
known  as  the  metatarsal,  gives  off  three  descending  branches,  which 
pass  downward  upon  the  second,  third,  and  fourth  interosseous  mus- 
cles as  far  as  the  webs  of  the  toes,  where  they  each  divide  into  two 
lateral  branches,  which  are  distributed  to  the  contiguous  halves  of 
the  adjoining  toes.  These  interosseous  branches  are  for  the  supply 
of  the  adjoining  sides  of  the  fifth  and  fourth,  fourth  and  third,  and 
third  and  second  toes.  The  dorsalis  pedis  itself  descends  upon  the  first 
interosseous  muscle,  this  part  of  the  artery — i.e..  between  the  first  and 
second  metatarsal  bones — being  called  the  dorsalis  hallucis;  it  divides 
to  supply  the  contiguous  sides  of  the  first  (big  toe)  and  second  toes, 
supplying  also  the  inner  side  of  the  big  toe. 


762  LOWER  EXTREMITY. 

The  first  dorsal  interosseous  muscle  is  perforated  above  by  a 
large  branch  of  the  dorsalis  pedis,  which  passes  through  to  the  deep 
part  of  the  sole  of  the  foot,  to  anastomose  with  the  external  branch 
of  the  posterior  tibial  to  form  the  plantar  arch. 

The  Anterior  Tibial  Nerve,  which  is  derived  from  the  external 
poiDliteal,  reaches  the  anterior  tibial  artery  at  the  junction  of  the  upper 
and  middle  thirds  of  the  leg,  and  then  accompanies  it  throughout  the 
rest  of  its  course.  The  nerve  reaches  the  anterior  tibial  artery,  as  this 
vessel  lies  upon  the  interosseous  membrane,  by  curving  around  the 
upper  part  of  the  fibula  beneath  the  extensor  longus  digitorum.  Cor- 
responding to  the  middle  third  of  the  leg,  the  nerve  lies  upon  the 
front  of  the  artery,  but  in  the  lower  part  of  the  leg  it  lies  to  the 
outer  side  of  the  artery,  and  beneath  the  anterior  annular  ligament 
divides  into  an  internal  and  an  external  branch. 

Ligation  of  the  Anterior  Tibial  Artery. — The  patient  lies 
upon  the  back,  with  the  knee  somewhat  flexed  and  a  sandbag  placed 
beneath  i't.  The  linear  guide  to  the  artery  corresponds  to  a  line  drawn 
from  the  inner  side  of  the  head  of  the  fibula  to  a  point  below,  midway 
between  the  internal  and  external  malleoli. 

The  vessel  may  be  tied  in  the  middle  third  of  the  leg,  as  it  lies 
upon  the  anterior  surface  of  the  interosseous  membrane  between  the 
tibialis  anticus  on  its  inner  side  and  the  extensor  proprius  pollicis  on 
its  outer  side. 

An  incision,  about  two  fingers'  breadth  external  to  the  prominent 
edge  of  the  shin  bone  and  two  or  three  inches  long,  is  made  through 
the  skin  and  fat  down  to  the  deep  fascia.  The  deep  fascia  is  then  in- 
cised, and  working  down,  between  the  tibialis  anticus  on  the  inner  side 
and  the  extensor  proprius  pollicis  on  the  outer  side,  with  the  handle  of 
the  scalpel,  the  interosseous  membrane  is  reached.  The  foot  is  then 
somewhat  flexed  at  the  ankle — dorsal  flexion — to  relax  the  muscles, 
and  retractors  are  introduced  deep  into  the  wound,  and  the  artery, 
with  its  venge  comites  lying  upon  it,  is  exposed.  The  anterior  tibial 
nerve  lies  in  front  of  the  anterior  tibial  vessels  in  this  part  of  their 
course.  After  the  nerve  has  been  separated  from  the  artery  a  liga- 
ture is  carried  around  the  vessel  from  without  inward  and  tied. 

The  Posterior  Tibial  Artery. — This  vessel  passes  down  the  back 
of  the  leg,  and  below,  between  the  internal  malleolus  and  the  tuber- 
osity of  the  OS  calcis,  it  divides  into  the  internal  and  external  plantar. 
The  posterior  tibial  is  larger  than  the  anterior,  and  at  its  origin  lies 
-deep  beneath  the  muscles  of  the  calf, — gastrocnemius  and  soleus, — 


LEG. 


763 


Fig.  336.— Section  through  the  Middle  of  the  Right  Leg.  A.A.V.,  anterior  tibial 
artery  and  vein;  G.E.,  gastrocnemius  externus;  O.I.,  gastrocnemius  internus; 
P.B.,  peroneus  brevis;  P.L.,  peroneus  longus;  P.V.,  peroneal  artery  and  vein; 
P.V.y.,  posterior  tibial  artery  and  nerve. 


76J:  LOWER  EXTREMITY. 

resting  upon  the  tibialis  jjosticus;  from  its  origin,  as  it  descends,  it 
gradiialh'  approaches  the  tibial  side  of  the  leg. 

In  the  loTrer  third  of  the  leg  the  artery  is  more  superficial,  run- 
ning parallel  with  the  inner  border  of  the  tendo  Achillis  and  being 
covered  onlj^  by  the  deep  fascia  and  the  integument.  The  posterior 
tibial  artery  is  accompanied  by  two  large  venge  comites,  one  on  either 
side  of  it. 

Between  the  os  calcis  and  the  inner  malleolus,  and  beneath  the 
origin  of  the  adductor  poUicis,  the  posterior  tibial  artery  divides  into 
its  terminal  branches,  the  internal  and  external  plantar.  The  in- 
ternal plantar,  the  smaller,  runs  along  the  inner  side  of  the  sole  of  the 
foot.  The  external  plantar  passes  outward,  beneath  the  flexor  brevis 
digitorum,  lying  upon  the  flexor  accessorius  as  far  as  the  base  of  the 
fifth  metatarsal  bone;  it  then,  turns  and  runs  inward  to  the  interval 
between  the  bases  of  the  first  and  second  metatarsal  bones,  where  it 
anastomoses  with  the  large  perforating  branch  from  the  dorsalis  pedis, 
and  thus  forms  the  plantar  arch. 

Erom  the  plantar  arch  four  digital  branches  descend  in  the  corre- 
sponding interosseous  spaces  as  far  as  the  webs  of  the  toes,  where  they 
divide  for  the  supply  of  the  adjacent  sides  of  the  toes.  The  contig- 
uous sides  of  the  big  toe  and  second  toe  and  the  inner  side  of  the  big 
toe  are  supplied  by  the  continuation  of  the  perforating  branch  of  the 
dorsalis  pedis,  which  divides,  at  the  cleft  between  the  big  and  second 
toes,  into  two  branches.  One  passes  inward  to  supply  the  inner  border 
of  the  great  toe  and  the  other  bifurcates  to  supply  the  contiguous  sides 
of  the  great  and  second  toes. 

As  the  posterior  tibial  artery  descends  in  the  middle  of  the  space 
between  the  os  calcis  and  the  internal  malleolus,  the  venge  comites 
lie  one  on  each  side  of  it;  the  posterior  tibial  nerve,  already  di- 
vided into  the  internal  and  external  plantar,  lies  to  its  outer  side; 
still  more  externally,  close  to  the  os  calcis,  is  the  tendon  of  the  flexor 
longus  pollicis,  and  to  the  inner  side  of  the  artery,  lodged  in  the  groove 
upon  the  posterior  border  of  the  internal  malleolus,  are  the  ten- 
dons of  the  tibialis  posticus  and  flexor  longus  digitorum;  of  these 
two,  the  tibialis  posticus  being  the  more  internal  and  the  closer  to  the 
bone. 

Just  below  its  origin  the  posterior  tibial  artery  gives  off  a  laxg-e 
branch,  the  peroneal;  this  branch  descends  along  the  fibular  side  of 
the  back  of  the  leg,  covered  by  the  soleus  and  gastrocnemius  and 
lying  upon  and  partly  covered  by  the  flexor  longus  pollicis. 


LEG.  765 

The  Posterior  Tibial  Nerve  accompanies  the  posterior  tibial 
artery;  it  is  the  continuation  of  the  internal  popliteal,  and  is  a  large 
nerve.  At  its  commencement  the  nerve  lies  to  the  inner  side  of  the 
artery,  bnt,  a  short  distance  from  its  origin  the  artery  passing  ob- 
liquely inward  toward  the  tibial  side  of  the  leg  and  the  course  of  the 
ner\'e  being  straight,  the  nerve  thereby  gets  to  lie  to  the  outer  side 
of  the  artery.  The  posterior  tibial  nerve  continues  down  the  back  of 
the  leg  upon  the  outer  side  of  the  artery,  and  divides,  in  the  space 
between  the  os  calcis  and  the  internal  malleolus,  into  the  internal  and 
external  plantar. 

Ligation  of  the  Posterior  Tibial. — This  vessel  may  be  ex- 
posed and  tied  just  above  the  ankle-joint  and  to  the  inner  side  of  the 
tendo  Achillis.  An  incision  is  made  about  two  inches  long  midway 
between  the  posterior  border  of  the  inner  malleolus  and  the  inner 
border  of  the  tendo  Achillis.  This  incision  reaches  through  the  integu- 
ment and  fat  down  to  the  deep  fascia.  The  deep  fascia  is  then  incised 
and  the  posterior  tibial  artery  exposed;  it  is  found  quite  superficial, 
together  with  its  xense  comites,  one  on  either  side.  To  the  outer  side 
of  the  vessels,  nearer  the  tendo  Achillis,  is  the  posterior  tibial  nerve. 
The  veins  are  separated  from  the  arterv,  and  a  ligature  then  carried 
around  the  artery  in  an  aneurism  needle,  from  within  outward  in 
order  to  avoid  the  nerve,  and  tied. 

Tenotomy.- — This  operation  is  done  with  a  narrnw-l)laded  knife 
through  a  very  small  incision  in  the  skin. 

Texdo  Achillis. — Tlie  foot  is  strongly  flexed  so  as  to  put  the 
tendon  upon  the  stretch,  and  a  narrow  tenotomy  knife  entered  close 
to  the  inner  border  of  the  tendon  and  about  one  and  one-half  inches 
above  its  attachment  to  the  os  calcis;  the  knife  is  entered  upon  the 
flat  and  pushed  through  the  soft  parts  in  front  of  the  tendon  as  far 
as  its  outer  border;  the  blade  of  the  knife  is  then  turned  so  that  its 
cutting  edge  is  directed  toward  the  tendon,  and  with  several  strokes 
the  tendon  is  divided.  The  division  of  the  tendon  is  really  accom- 
plished by  strongly  flexing  the  foot  and  thus  making  the  tendon  very 
tense  upon' the  sharp  edge  of  the  knife. 

There  is  no  danger  of  wounding  the  posterior  tibial  vessels  and 
nerve  if  the  blade  of  the  knife  is  introduced  close  to  the  inner  border 
of  the  tendon  (see  Posterior  Tibial  Artery,  etc.). 

Texdoxs  of  the  Tibialis  Posticus  axd  Flexor  Loxgus  Digi- 
torum. — These  tendons  are  divided  as  they  descend  in  the  groove 
upon  the  posterior  border  of  the  internal  malleolus. 


r^QQ  LOWER  EXTREMITY. 

The  inner  edge  of  this  groove,  which  marks  the  posterior  border 
of  the  internal  malleolus,  should  be  recognized  and  the  tenotomy  knife 
introduced  upon  the  flat,  so  that  it  enters  in  front  of  the  tendons, 
between  the  tendons  and  the  floor  of  the  groove  upon  the  posterior 
border  of  the  internal  malleolus.  The  knife  is  then  turned  so  that  its 
cutting  edge  is  directed  toward  the  tendons,  and  by  forcibly  flexing 
(dorsal  flexion)  the  foot  and  everting  it,  thus  making  the  tendons  tense, 
their  division  is  accomplished  (see  Posterior  Tibial  Arterj^,  etc.). 

OPERATIONS    FOR   VARICOSE   VEINS. 

Varicose  Veins  usually  involve  the  veins  upon  the  inner  and 
back  side  of  the  leg  and  the  inner-anterior  aspect  of  the  thigh,  along 
the  course  of  the  internal  saphenous.  The  veins  become  increased 
in  length,  tortuous,  irregularly  dilated  and  pouched,  the  walls  very 
much  thickened  in  some  places  and  very  thin  in  others.  The  affected 
veins,  especially  over  bony  surfaces,  are  liable  to  injury  or  may 
rupture  spontaneously  with  severe  hemorrhage.  Ulcers  may  develop 
and  the  skin  may  be  eczematous,  and  the  veins  may  become  inflamed 
and  thrombosed. 

The  superficial  veins  of  the  leg  may  be  considered  as  consisting 
of  two  groups.  The  branches  of  one  or  both  of  these  groups  may 
be  affected  in  varicose  veins  of  the  leg.  The  veins  of  the  outer  and 
posterior  sides  of  the  leg  join  to  form  the  external  or  short  saphenous 
vein,  and  the  veins  upon  the  inner  and  anterior  surfaces  of  the  leg 
are  tributary  to  the  internal  saphenous.  In  the  leg  the  main  trunks 
of  the  external  saphenous  and  internal  saphenous  veins  are  accom- 
panied by  the  external  and  internal  saphenous  nerves,  and  these 
should  be  avoided  in  applying  ligatures  to  the  veins. 

The  Inteenal  or  Long  Saphenous  Vein  drains  the  inner 
and  anterior  aspects  of  the  leg.  It  ascends  upon  the  inner  side  of 
the  knee,  lying  just  posterior  to  the  internal  condyle,  and  continues 
upward  in  the  thigh  to  join  the  femoral  vein  in  the  upper  part  of 
Scarpa's  triangle.  In  the  leg  the  main  trunk  of  the  vein  is  accom- 
pained  by  the  internal  or  long  saphenous  nerve. 

The  External  or  Short  Saphenous  Vein  drains  the  outer 
and  back  sides  of  the  leg.  It  commences  by  the  union  of  a  number 
of  venous  branches  upon  the  outer  side  of  the  foot,  passes  upward 
behind  the  external  malleolus,  ascends  along  the  outer  border  of  the 
tendo  Achillis,  and  continues  up  the  back  of  the  leg  as  far  as  the 
popliteal  space,  where  it  pierces  the  deep  fascia  to  terminate  in  the 


OPERATIONS  FOR  VARICOSE  VEINS.  767 

popliteal  vein.  The  vein  is  accompanied  by  the  external  saphenous 
nerve. 

Trendelenburg  Operation.— This  operation  consists  in  ligation 
and  excision  of  a  portion  of  the  internal  saphenous  vein  in  the  upper 
part  of  the  thigh.  According  to  Trendelenburg  the  varicosities  are 
due  to  the  fact  that  the  valves  in  the  internal  saphenous  have  become 
incompetent  and  the  weight  of  the  entire  column  of  venous  blood 
from  the  vena  cava  is  placed  upon  the  terminal  veins,  which  thus 
become  stretched,  elongated,  tortuous  and  varicosed.  This  condition 
maj'  be  demonstrated  by  elevating  the  lower  limb  with  the  patient 
lying  down  so  as  to  empty  the  limb  as  nearly  completely  as  possible 
of  venous  blood.  While  the  limb  is  held  in  the  elevated  position  a 
bandage  is  applied  around  the  lower  part  of  the  thigh,  just  tight 
enough  to  obstruct  the  venous  flow.  The  patient  is  then  directed  to 
stand  up,  and  if  the  saphenous  vein,  above  the  bandage,  becomes  dis- 
tended with  blood,  the  vein  filling  from  above  due  to  the  blood 
dropping  back  into  the  vein  without  any  resistance  being  offered  upon 
the  part  of  the  valves,  it  shows  that  these  are  incompetent,  that  they 
offer  no  support  to  the  column  of  blood,  and  that  the  Trendelenburg 
operation  is  indicated. 

An  incision  about  four  inches  long  is  made  in  the  upper  part 
of  the  thigh  and  corresponding  to  the  course  of  the  internal  saphenous 
vein.  The  vein  is  exposed  in  the  incision,  its  branches  ligated  double 
with  plain  catgut.  Each  branch  is  divided  between  the  ligatures.  The 
vein  is  ligated  in  the  upper  part  of  the  incision  and  in  the  lower 
part  and  the  intervening  portion,  three  or  four  inches,  resected. 

Schede's  Operaton. — No  tourniquet  is  necessary.  It  is  of 
advantage  to  commence  the  operation  by  exposing  and  tying  the  veins 
that  go  to  make  up  the  internal  saphenous  just  above  the  knee-joint. 
For  this  purpose  a  transverse  incision  is  made  upon  the  inner  side 
of  the  thigh,  about  four  inches  above  the  knee-joint.  This  incision 
is  three  or  four  inches  long.  It  penetrates  into  the  subcutaneous  fat 
layer  down  to  the  deep  fascia  and  exposes  the  several  large  sub- 
cutaneous venous  branches  that  represent  the  internal  saphenous  vein. 
They  may  be  very  much  dilated  and  sacculated.  These  several 
branches  are  tied  double  with  plain  catgut  and  divided  between  the 
ligatures.  The  incision  is  closed  with  several  sutures  and  a  wet 
bichloride  towel  placed  over  it  temporarily,  until  the  rest  of  the 
operation  has  been  completed. 

In  order  to  expose  the  varicosed  subcutaneous  branches  in  the 


768 


LOWER  EXTREMITY. 


leg  a  circular  incision  is  made  wliicli  penetrates  into  the  subcutaneous 
fat  layer  down  to  the  deep  fascia.  This  incision  is  made  all  around 
the  leg,  about  on  a  level  with  the  bulging  part  of  the  calf — five  or 
six  inches  below  the  knee-joint.  The  incision  is  carried  all  around 
the  leg,  but  not  all  at  once.     The  incision  is  made  around  the  leg, 


Fig.  338.— Operation  for  Varicose  Veins. 
Incision  exposes  the  external  saphenous 
and  its  tributaries. 


Fig.  337. — Operation  for  Varicose  Veins, 
where  the  internal  saphenous  and  its 
tributaries  are  affected.  Incision  above 
knee  through  which  the  internal  saphe- 
nous is  exposed  and  ligated.  Circular  in- 
cision around  the  leg  to  expose  and  ligate 
all  the  affected  veins. 


little  by  little,  exposing  and  ligating  the  veins  as  they  are  met  with. 
The  incision  is  first  made  only  part  way  around  the  leg  and  the 
vessels  which  are  exposed  in  this  part  of  the  incision  are  tied  double 
and  cut.  The  incision  is  then  carried  farther  around  the  leg  and 
again  the  veins  that  are  exposed  are  tied  double  and  cut  between  the 


OPERATIONS  FOR  VARICOSE  VEINS.  769 

ligatures.  Proceeding  in  this  way  much  loss  of  blood  is  avoided.  The 
larger  veins  may  usually  be  seen,  clamped  double,  and  ligated  before 
they  are  cut.  Some  of  the  smaller  veins  will  not  be  recognized  until 
they  have  been  cut.  They  are  caught  with  clamps  and  ligated.  The 
incision  penetrates  down  to  the  deep  fascia  throughout  its  entire 
extent,  thus  making  certain  that  no  veins  have  been  overlooked.  It 
will  not  be  necessary,  in  some  cases,  to  carry  the  incision  entirely 
around  the  leg,  only  around  that  part  which  corresponds  to  the 
location  of  the  varicose  veins. 

The  edges  of  the  skin  are  brought  together  with  interrupted 
sutures  of  silk-worm  gut. 

Madelung's  Operatiox. — This  operation  consists  in  stripping 
and  excising  the  individual  varicosed  veins.  This  plan  is  especially 
adapted  to  those  cases  where  the  varicosities  are  fairly  definitely 
limited  to  several  larger  individual  veins.  Above  in  the  thigh,  or  in 
the  leg,  corresponding  to  the  course  of  the  internal  saphenous  or  to 
the  vein  or  veins  that  are  to  be  excised,  a  longitudinal  incision  which 
exposes  the  enlarged  varicosed  vein  is  made.  The  vein  is  picked  up, 
tied  double,  and  divided  lietween  the  ligatures.  The  lower  end  of 
the  vein  is  drawn  through  the  ring  of  a  blunt  dissector,  which  is  made 
for  the  purpose,  and  the  vein  then  separated  with  the  dissector  as 
far  as  it  can  be  reached.  As  the  venous  trunk  is  separated  and  drawn 
out  of  the  incision  its  tributaries  are  clamped  and  tied  and  cut  as 
they  are  met  with.  Having  proceeded  as  far  as  possil^le  along  the 
course  of  the  vein  through  the  first  incision,  a  second  is  made  by 
incising  the  skin  over  the  ring  of  the  dissector,  which  is  presented 
under  the  skin,  and  the  length  of  vein  which  has  already  been  isolated 
is  drawn  out  through  this  second  incision.  The  vein  may  then  be 
followed  farther  along  its  course,  making  still  a  third  incision  farther 
down  the  leg  if  necessary.  One  or  several  veins  may  be  treated  in 
this  manner,  according  to  the  number  of  enlarged  venous  trunks  that 
are  present.  The  first  incision  is  usually  placed  about  the  middle  of 
the  thigh,  and  is  two  to  three  inches  long. 

If  the  varicose  veins  are  limited  to  the  leg  a  transverse  incision 
may  be  made  which  extends  part  way  around  the  upper  part  of  the 
leg  so  as  to  expose  the  several  varicosed  veins.  The  veins  are  tied 
double  and  divided,  and  may  then  be  followed  down  the  leg  with 
the  ring  dissector  in  a  manner  similar  to  that  described  above. 

Varicose  Ulcer. — The  ulcer  associated  with  varicose  veins  may 
be  treated  very  satisfactorily  by  surgical  operation.     After  the  veins 


770 


LOWER  EXTREMITY. 


leading  up  from  the  ulcer  have  been  ligated  and  divided  according 
to  the  plans  described  above,  the  base  of  the  nicer  is  excised  and 
the  surface  covered  with  skin-grafts.  In  some  cases  it  is  advantageous 
to  make  an  incision  a  short  distance  below  the  ulcer  and  ligate  and 
divide  the  veins  that  lead  from  below,  up  to  the  ulcer. 

AMPUTATIONS,  RESECTIONS,  ETC. 

Surgical  Anatomy  of  the  Skeleton  of  the  Foot. — A  knowledge 
of  the  composition  and  articulations  of  the  skeleton  of  the  foot  is  of 


Fig.  339. — Right  Foot.     C,  Cliopart  articulation;  C",  incision  for  Chopart  amputa- 
tion; L,  Lisfranc  articulation;   L',  incision  for  Lisfranc  amputation. 

much  practical  value  in  performing  the  various  amputations   upon 
this  part. 

The  tarsus  is  made  up  of  two  rows— or,  better,  two  groups — of 
irregular-shaped  bones.  The  first  row  consists  of  the  os  calcis  and 
astragalus,  the  os  calcis  occupying  the  outer  side  of  the  foot  and  form- 
ing the  heel,  the  astragalus  being  on  the  inner  side  of  the  foot,  par- 
tially resting  upon  the  os  calcis  and  entering  into  the  formation  of 
the  ankle-joint..  The  anterior,  articular  surfaces  of  these  bones  are 
on  about  the  same  plane,  and  form  an  uninterrupted  line  from  the 
outer  to  the  inner  side  of  the  foot.    The  anterior,  articular  surface  of 


AMPUTATIONS,  RESECTIONS,  ETC.  771 

the  astragalus  is  convex,  and  is  located  al)ove  and  to  the  inner  side  of 
that  of  the  os  calcis,  which  is  rather  concave. 

The  second  group  consists  of  the  cuboid,  whicli  is  on  the  outer 
side  of  the  foot,  articulating  with  the  os  calcis ;  the  scaphoid,  which 
is  on  the  inner  side  of  the  foot,  articulating  behind  with  the  astragalus ; 
and  the  three  cuneiforms.  This  second  group  presents  anteriorly  an 
irregular  row  of  articular  surfaces  which  is  convex  toward  the  toes, 
its  outer  end  being  about  one  inch  nearer  the  ankle-joint  than  its 
inner  end. 

We  next  come  to  the  metatarsal  bones,  five  in  number,  which 
articulate  as  follows :  The  two  outer,  those  of  the  little  toe  and  the 
fourth,  with  the  cuboid;  the  third,  middle  one,  with  the  external 
cuneiform ;  the  second  with  the  middle  cuneiform ;  and  the  first, 
that  of  the  big  toe,  with  the  internal  cuneiform.  The  base  of  the 
fifth  metatarsal  bone  presents  a  prominent  tuberosity,  which  pro- 
jects outward  and  is  easily  felt  underneath  the  skin;  this  is  an  im- 
portant surgical  guide.  The  second  metatarsal  bone  is  characterized 
by  its  base  projecting  backward,  into  the  tarsus,  beyond  the  bases  of 
the  adjoining  metatarsal  bones;  so  that  the  tarso-metatarsal  artic- 
ular line  is  interrupted  at  this  point. 

We  therefore  have  an  articular  junction  between  the  os  calcis  and 
astragalus  behind  and  the  cuboid  and  scaphoid  in  front,  which  we 
might  call  the  Chopart  joint.  Through  this  Ave  do  the  Chopart 
amputation.  The  inner  end  of  the  scaphoid  presents  a  prominent 
tuberosity,  which  is  readily  felt  beneath  the  skin  just  below  and  in 
front  of  the  tip  of  the  inner  malleolus;  this  tubercle  is  the  guide  to 
the  inner  end  of  the  Chopart  joint,  the  outer  end  of  the  joint  being 
located  one  thumb's  breadth  behind  the  tuberosity  Avhich  marks  the 
base  of  the  fifth  metatarsal  bone. 

The  articular  line  between  the  tarsus  behind  and  the  metatarsus 
in  front  might  be  called  the  Lisfranc  junction.  This  line  is  curved, 
with  its  convexity  forward  toward  the  toes.  The  outer  end  of  the 
junction  corresponds  to  the  base  of  the  metatarsal  bone  of  the  little 
toe,  which  presents  a  prominent  tuberosity  that  may  be  readily  felt 
and  which  is  the  guide  to  the  joint.  The  inner  end  of  the  Lisfranc 
junction  is  lower  than  the  outer,  being  about  one  inch  nearer  the  toes, 
and  may  be  located  two  fingers'  breadth  in  front  of  the  tuberosity  of 
the  scaphoid. 

The  line  of  the  Lisfranc  articulation  is  interrupted  by  the  pro- 
jection of  the  base  of  the  second  metatarsal  bone  rather  less  than  one- 


773  LOWER  EXTREMITY. 

fourth  inch  farther  into  the  tarsus  than  the  third  metatarsal,  and  again 
by  the  fact  that  the  articulation  between  the  first  metatarsal  (big 
toe)  and  the  internal  cuneiform  is  about  half  an  inch  lower,  nearer 
the  toe,  than  that  between  the  second  metatarsal  and  the  middle 
cuneiform. 

ExARTicuLATiON  OF  THE  BiG  ToE.  Ovol  Method. — The  toe  is 
seized  with  the  left  hand  and  a  dorsal  incision  made  upon  the  head 
(lower  extremity)  of  the  metatarsal  bone,  commencing  about  one-half 
inch  above  the  metatarso-phalangeal  joint;  this  incision  is  carried 
straight  down  to  a  point  about  one-half  inch  beyond  the  web  of  the 
toe  and  then  around  the  toe,  cutting  everything  to  the  bone. 

One  should  remember  that  the  head  of  the  metatarsal  bone  of  the 
big  toe  is  large  and  requires  a  considerable  flap  to  cover  it.  The  cor- 
ners of  the  flap  are  seized  first  on  one  side  and  then  on  the  other, 
and  the  flap  dissected  away  from  the  bone.  Flexing  the  toe,  the 
joint  is  opened  upon  its  dorsal  aspect,  the  lateral  ligaments  being 
divided,  while  the  toe  is  pulled  first  to  one  side  and  then  to  the  other, 
and  finally  the  remaining  attached  soft  parts  are  separated,  cutting 
close  to  the  bone  and  from  within  outward.  Spurting  vessels  are 
clamped  and  tied  and  the  wound  closed  with  four  or  five  interrupted 
catgut  sutures.  A  small  drain  may  be  left  in  situ  for  two  days.  Am- 
putation of  the  other  toes  is  done  in  a  manner  analogous  to  the  above. 

EXARTICULATION  OF  THE  BiG  TOE,  WITH  E.EMOVAL  OP  THE  FiRST 

Metatarsal  Bone.- — An  incision  is  made  which  begins  just  above  the 
tarso-metatarsal  joint,  articulation  of  the  metatarsal  with  the  internal 
cuneiform,  which  is  located  about  one  finger's  breadth  below  the 
tuberosity  of  the  scaphoid,  and  this  is  carried  down,  upon  the  dorsal 
surface  of  the  foot,  to  the  web  of  the  toe,  at  which  point  it  is  carried, 
in  the  form  of  an  oval,  around  the  toe  (see  Fig.  355).  This  incision, 
throughout  its  whole  extent,  reaches  to  the  bone.  The  edges  of  the 
incision  are  drawn  apart  with  retractors,  and  the  soft  parts  separated 
from  the  metatarsal  bone,  after  which  the  joint  above,  between  the 
metatarsal  and  internal  cuneiform  bones,  is  opened  and  the  meta- 
tarsal enucleated  out  of  its  bed  of  soft  parts,  cutting  with  the  edge 
of  the  knife  close  to  the  surface  of  the  bone. 

The  tendons  of  the  big  toe  are  cut  short  above  at  the  level  of  the 
tarso-metatarsal  joint.  It  is  unnecessary  to  use  a  tourniquet  in  this 
amputation.  Spurting  vessels  are  caught  and  tied,  and  after  the  bleed- 
ing has  been  checked  the  wound  is  closed  with  several  interrupted 
catgut  sutures.    The  incision  may  be  placed  upon  the  side  of  the  foot 


AMPUTATIONS,  RESECTIONS,  ETC. 


773 


instead  of  upon  the  dorsum  :  this  is  better  for  drainajze.  but  the  scar 
is  not  so  well  located. 

ExARTicuLATiON  OF  THE  LiTTLE  ToE. — Amputation  of  the  little 
toe  and  its  metatarsal  bone  may  be  done  in  a  manner  similar  to  the 
preceding. 

For  Bunion  (Hallux  Valgus). — This  condition  consists  in 
a  prominent  angulation  at  the  metatarso-phalangeal  joint  of  the  first 
(big)   toe  due  to  the  displacement  outward,  toward  the  middle  line 


EX.  HAL, 


uM^ 


Fig.  340.— Osteotomy    for    Bunion.       EX.HAL.,   tendon    of   the   extensor   proprius 
haUucis.     Arrow  indicates  line  of  division  of  metatarsal  of  big  toe. 


of  the  foot,  of  the  big  toe.  The  inner  portion  of  the  head  of  the 
first  metatarsal  bone  and  the  corresponding  portion  of  the  articular 
surface  of  the  first  phalanx  gradually  become  hypertrophied,  with 
the  result  that  the  corresponding  articular  surfaces  of  the  two  bones 
assume  a  plane  which  is  oblique  to  the  long  axes  of-  the  bones,  and 
thus  the  altered  position  of  the  toe  becomes  permanent.  A  bursa  is 
gradually  developed  over  the  prominent  angle.  This  bursa  is 
peculiarly  subject  to  bruising,  pressure,  attacks  of  acute  inflammation, 
etc.,  and  may  be  the  source  of  much  pain  and  discomfort.  Osteotomy 
of  the  distal  end  of  the  metatarsal  bone,  or  resection  of  the  head  of 
the  bone,  may  be  necessary  to  correct  the  condition. 


774  LOWER  EXTREMITY. 

Osteotomy  of  the  First  Metatarsal  Bone. — The  metatarsal  bone 
of  the  big  toe  is  divided  at  a  jDoint  just  posterior  to  its  anterior  ex- 
tremity^ (head).  A  longitudinal  incision  is  made  upon  the  inner  side 
of  the  foot.  The  incision  is  about  one  inch  long  and  is  placed  just 
posterior  to  the  location  of  the  metatarsophalangeal  joint,  so  as  to 
expose  the  anterior  end  of  the  first  metatarsal  bone.  The  incision 
is  placed  nearer  the  dorsal  than  the  plantar  surface  of  the  foot 
(this  position  is  better  for  the  scar  that  results)  and  penetrates 
through  all  the  soft  parts  down  to  the  bone.  The  osteotome,  chisel, 
is  introduced  in  the  incision  down  to  the  bone.  The  chisel  is  turned 
so  that  its  edge  occupies  a  position  at  right  angles  to  the  long  axis 
of  the  metatarsal  bone,  and  rests  firmly  upon  the  bone  about  one- 
Iialf  inch  behind  its  articular  end.  The  bone  is  divided  at  this  point 
with  several  blows  of  the  mallet.  In  some  cases  it  will  be  more 
satisfactory^  to  resect  a  wedge-shaped  piece  of  the  bone  instead  of 
making  the  simple  linear  osteotomy  described  above.  The  toe  is 
then  restored  to  its  natural  straight  position.  The  incision  is  closed 
without  drainage,  dressings  applied,  and  the  foot  placed  in  plaster 
of  Paris.  It  may  be  necessar)^  in  some  cases  to  divide  the  tendon  of 
the  extensor  proprius  hallucis  if  it  has  become  relatively  so  short 
that  it  interferes  with  the  proper  reposition  of  the  toe. 

According  to  Mayo  bunion  is  corrected  by  excising  the  bursa  and 
resecting  the  head  of  the  metatarsal  bone.  The  raw  end  of  the 
metatarsal  bone  is  then  covered  over  by  turning  a  piece  of  the  synovial 
lining  of  the  bunion  into  the  joint.  A  portion  of  the  bursa  is  left 
for  this  purpose.    In  this  way  ankylosis  of  the  joint  is  prevented. 

Foe  Hammer-Toe. — This  condition  can  be  corrected  as  a  rule 
by  subcutaneous  division  of  the  flexor  tendons  of  the  affected  toe 
and  by  forcibly  extending  the  toe.  After  the  tendons  have  been 
divided  and  the  toe  straightened  it  will  usually  be  found  that  the 
skin  on  the  under,  flexor,  side  of  the  toe  is  so  tense  that  it  will  be 
necessary  to  incise  it.  A  V-shaped  incision  with  the  point  of  the  Y 
upward,  toward  the  web  of  the  toe  is  made.  Under  these  circum- 
stances we  have  an  open  wound  which  heals  by  granulation. 

This  condition  may  also  be  corrected  by  resecting  the  articular 
end  of  one  of  the  phalanges  of  the  affected  joint.  The  articulation 
can  be  reached  through  an  incision  upon  its  dorsal  aspect.  The  joint 
is  opened  and  one  end  of  either  one  or  the  other  phalanx  resected.  It 
will  be  necessary  in  these  cases,  also,  to  divide  the  flexor  tendons  of  the 
affected  toe. 


AMPUTATIONS,  RESECTIONS,  ETC.  775 

For  Ingrowing  Toe-nail.  Removal  of  the  Offending  Half 
of  the  Nail. — This  operation  is  done  under  local  cocain  ana2sthe- 
sia.  A  rubber  band  is  tied  tight  around  the  root  of  the  toe  for  the 
purpose  of  confining  the  cocain  to  this  part  and  in  order  to  control 
the  hemorrhage.  The  end  of  a  sharp-pointed  scissors  is  pushed  under 
the  nail  and  down  the  middle,  as  far  as  the  root,  and  with  this  the  nail 
is  split.  The  half  of  the  nail  which  is  to  be  removed  is  then  grasped 
with  an  artery  forceps  and  torn  away  from  the  matrix. 

Catting  Operation. — Cocain  anaesthesia.  A  I'ubljer  band  is  tied 
around  the  root  of  the  toe.  The  soft  parts,  corresponding  to  the 
affected  side  of  the  toe,  are  transfixed  with  a  long,  narrow-bladed  knife 


Fig.  341.— Operations  for  Ingrowing  Toe-nail.     Solid  line  indicates  Cotting  opera- 
tion.   Dotted  line  shows  line  of  incision  for  removal  of  half  of  the  nail. 

and  excised.  The  incision  should  extend  backward  well  beyond  the 
root  of  the  nail.  In  addition,  the  corresponding  half  of  the  nail  may  be 
removed  as  described  above.  The  bleeding  digital  branch  upon  the 
outer  side  of  the  toe  may  be  clamped  and  tied.  Although  a  snug  band- 
age and  elevation  of  the  limb  usually  suffice  to  control  the  hemorrhage, 
still  it  is  wise  to  ligate  the  bleeding  point.  The  raw  surfaces  are  dis- 
infected and  covered  with  a  wad  of  gauze  and  a  bandage  applied. 

Amputation  through  the  Tarso-metatarsal  Articulation 
(LiSFRANc). — A  tourniquet  is  applied  just  above  the  knee.  The  right 
foot,  for  example.  The  foot  should  extend  over  the  end  of  the  table. 
The  guides  to  the  Lisfranc  joint  are,  on  the  outer  side  of  the  foot,  the 
prominent  base  of  the  fifth  metatarsal  bone  (little  toe)  and,  on  the 
inner  side,  the  base  of  the  first  metatarsal  (big  toe)  which  is  located 


776  LOWER  EXTREMITY. 

a  finger^s  breadth  in  front  of  the  tuberosity  of  the  scaphoid.  The 
lower  part  of  the  foot  is  grasped  in  the  left  hand  (the  palm  of  the 
hand  applied  to  the  sole  of  the  foot),  with  the  thumb  upon  the  outer 
guide  and  the  index  finger  upon  the  inner  guide,  and  a  curved 
incision,  with  its  convexity  downward  toward  the  toes,  is  then  made; 
this  incision  extends  across  the  dorsum  of  the  foot,  from  its  outer 
to  its  inner  border,  commencing  and  ending  a  little  below  the  level 
of  the  joint,  so  that  when  the  skin  retracts  it  will  not  leave  the  ends 
of  the  bones  protruding  beyond  the  edge  of  the  flap  (see  Fig.  339). 
An  incision  is  then  carried  down,  along  the  outer  and  inner  borders  of 
the  foot,  from  either  end  of  the  dorsal  incision,  as  far  as  the  web  of  the 
toes. 

The  short  flap  which  has  been  marked  out  upon  the  dorsum  of 
the  foot  is  dissected  back  to  the  level  of  the  articulation  and  should 
include  only  the  integument  and  the  subcutaneous  fat. 

IvTow,  forcibly  flexing  the  foot,  the  extensor  tendons  on  the  dor- 
sum are  divided  to  the  bone  and  the  point  of  the  knife  inserted  into 
the  joint  behind  the  base  of  the  metatarsal  bone  of  the  little  toe,  and 
this  joint  thus  opened.  The  knife  is  then  carried  inward  across  the 
foot,  remembering  that  the  line  of  the  joint  is  not  straight,  but  con- 
vex, the  convexity  being  directed  forward  toward  the  toes. 

When  we  reach  the  point  where  the  base  of  the  metatarsal  bone 
of  the  second  toe  projects  into  the  tarsus,  the  edge  of  the  knife  is 
turned  backward  toward  the  ankle  for  about  one-fourth  inch,  and 
then,  again  turning  it  inward,  the  joint  between  the  base  of  the 
second  metatarsal  and  the  middle  cuneiform  is  opened.  The  edge  of 
the  knife  is  then  turned  forward  toward  the  toes,  and  carried  in  this 
direction  for  about  one-half  inch,  in  order  to  reach  the  level  of  the 
joint  between  the  first  metatarsal  (big  toe)  and  the  internal  cunei- 
form, which  is  then  also  opened. 

Flexing  the  foot  still  more  forcibly,  thus  causing  the  joint  to 
gape  widely,  the  metatarsus,  the  portion  of  the  foot  which  is  to  be 
amputated,  is  freed  with  the  point  of  the  scalpel  upon  its  deep  plantar 
aspect,  and  then,  with  the  long  knife,  and  cutting  close  to  the  bone, 
all  the  'soft  parts  are  separated  upon  the  plantar  aspect  of  the  foot 
down  to  the  webs  of  the  toes,  at  which  point  the  long  plantar  flap  is 
cut  from  within  outward  and  the  amputation  is  complete. 

It  will  be  necessary  to  clamp  and  tie  the  dorsalis  pedis  upon  the 
dorsal  surface  of  the  foot,  near  the  inner  border,  and  in  the  large 
plantar  flap  the  branches  of  the  plantar  arch. 


AMPUTATIONS,  RESECTIONS,  ETC. 


777 


We  have  upon  the  dorsum  a  short,  semilunar  flap  which  is  com- 
posed of  skin  and  fat  only,  and  upon  the  plantar  aspect  a  long  flap 


Fig.  342. — Right  Foot,  Inner  Side.    C,  incision  for  Chopart:  L,  incision 
for  Lisfranc;   P,   incision  for   Pirogoft. 


Fig.  343. — Right  Foot,  Outer  Side.     C,  incision  for  Chopart;  L,  incision 
for  Lisfranc:    P,   incision  for  Pirogoff. 


composed  of  all  the  structures  of  the  sole  of  the  foot.     The  edges  of 
these  flaps  are  brought  together  with  interrupted  catgut  sutures. 

In  amputating  the  left  foot  it  is  grasped  in  tlie  same  way  by  the 


778  LOWER  EXTREMITY. 

operator,  indicating  the  bony  guides  with  his  finger  and  thumb,  the 
incision  being  made  from  the  inner  toward  the  outer  border  of  the 
foot. 

AMPUTATIOlSr  THEOUGH  THE  MeDIO-TAESAL  JoINT    (ChOPAEt). 

The  tourniquet  is  placed  around  the  limb  above  the  knee-joint.  The 
right  foot,  for  example.  The  foot  extends  over  the  end  of  the  table. 
The  guide  to  the  Chopart  joint,  on  the  inner  side  of  thei  foot,  is  the 
tubercle  of  the  scaphoid;  on  the  outer  side  of  the  foot  we  measure  a 
thumb's  breadth  behind  the  -tuberosity  which  marks  the  base  of  the 
fifth  metatarsal  bone,  in  order  to  locate  the  outer  end  of  the  joint. 
The  foot  is  grasped  with  the  left  hand,  as  described  in  the  Lisfranc, 
the  index  finger  on  the  inner  guide,  tubercle  of  scaphoid,  and  the 
thumb  marking  the  level  of  the  joint  externally. 

As  in  the  Lisfranc,  a  short  anterior  flap  is  marked  out  by  making 
a  dorsal  incision,  curved,  with  the  convexity  forward  toward  the  toes. 
This  incision  commences  at  the  outer  border  of  the  foot  rather  in 
front  of  the  line  of  the  joint  (nearer  the  toes)  and  ends  on  the  inner 
side  of  the  foot,  likewise  in  front  of  the  line  of  the  joint  (see  Fig.  339) . 
From  either  end  of  this  dorsal  incision  a  lateral  incision  is  carried 
forward,  along  either  border  of  the  foot,  toward  the  toes. 

The  short  anterior  flap  is  now  seized  and,  including  only  the 
skin  and  fat,  is  reflected  back  a  little  beyond  the  line  of  the  joint. 
Forcibly  flexing  the  foot,  the  medio-tarsal  joint  is  then  opened,  from 
within  outward,  by  inserting  the  point  of  the  knife  into  the  joint 
immediately  behind  the  tubercle  of  the  scaphoid  so  as  to  enter  be- 
tween this  bone  and  the  head  of  the  astragalus;  then,  continuing 
outward  toward  the  outer  border  of  the  foot,  the  joint  between  the 
cuboid  and  the  os  calcis  is  opened,  care  being  taken  not  to  enter, 
by  mistake,  the  joint  between  the  astragalus  and  the  os  calcis. 

Flexing  the  foot  still  more  forcibly,  and  thus  causing  the  opened 
joint  to  gape,  the  plantar  ligaments,  which  bind  the  bones  together, 
are  divided  with  the  scalpel,  and  then  a  long  knife  is  introduced 
into  the  joint  and  the  long  plantar  flap  cut  with  a  sawing  motion, 
the  edge  of  the  knife  being  applied  close  to  the  bones,  thus  separat- 
ing all  the  plantar  soft  parts  from  the  bones  as  far  down  as  the 
heads  of  the  metatarsal  bones,  where,  with  a  cut  from  within  out- 
ward, the  long  plantar  flap  is  completed. 

It  is  necessary  to  catch  the  stump  of  the  dorsalis  pedis  near 
the  inner  side  of  the  foot,  upon  the  dorsal  surface,  and  the  branches 
of  the  plantar  arch  in  the  long  posterior  flap.     The  dorsal  flap  is 


AMPUTATIONS,  RESECTIONS,  ETC.  779 

short,  and  consists  of  skin  and  fat;  the  phuitar  flap  is  long,  and  in- 
cludes all  the  soft  parts  of  the  sole  of  the  foot.  The  edges  of  the 
flaps  are  united  with  several  interrupted  catgut  or  silkworm-gut 
sutures. 

In  operating  upon  the  left  foot  it  is  grasped  by  the  surgeon  in 
the  same  way,  the  incision  marking  out  the  dorsal  flap  being  made 
from  the  inner  toward  the  outer  border  of  the  foot. 

Owing  to  the  action  of  the  tendo  Achillis,  the  stump  which  re- 
sults is  very  apt,  after  a  time,  to  become  extended  at  the  ankle-joint; 
in  order  to  avoid  this  the  division  of  the  tendo  Achillis  has  been 
recommended.  This,  however,  helps  but  little,  and  many  surgeons 
have  discarded  this  method  of  amputation  entirely. 

Surgical  Anatomy  of  the  Ankle-joint. — The  ankle-joint  is  formed 
by  the  lower  ends  of  the  tibia  and  fibula  and  the  astragalus.  The 
lower  ends  of  the  tibia  and  fibula  are  bound  together  by  the  so-called 
interosseous  ligament,  thus  forming  an  arched  concavity  into  which 
the  articular  surface  of  the  astragalus  is  received.  The  outer  por- 
tion of  the  tibio-fibular  arch  is  formed  by  the  external  malleolus 
(lower  end  of  fibula),  which  extends  a  finger's  breadth  lower  than 
the  inner  malleolus;  the  vault  and  inner  buttress  of  the  arch  are 
formed  by  the  lower  articular  surface  of  the  tibia  and  the  inner 
malleolus.  The  articular  surface  of  the  tibia  is  broader  in  front  than 
behind. 

The  articular  surface  of  the  astragalus  presents  an  upper, 
smooth  surface,  which  slopes  downward  and  backward  and  which  is 
also  wider  in  front  than  behind,  and  is  continuous,  on  each  side,  with 
a  lateral,  smooth  facet  for  articulation  Avith  the  inner  and  outer 
malleoli. 

The  joint  is  provided  with  a  capsular  ligament,  which  is  de- 
scribed as  consisting  of  several  separate  portions.  Behind,  it  is 
very  thin  and  membranous,  but  is  thicker  in  front  and  upon  the 
sides. 

The  capsule  is  attached  above,  anteriorly  and  posteriorly,  to  the 
margin  of  the  tibia  and  fibula,  and  on  the  sides  to  the  margins  of  the 
inner  and  outer  malleoli;  below  it  is  attached  to  the  adjacent  rough 
surface  of  the  astragalus  and  the  os  calcis,  some  of  the  fibers  on  the 
inner  side  extending  forward  to  the  scaphoid. 

The  joint  is  provided  with  a  synovial  membrane,  which  is  applied 
to  the  inner  aspect  of  the  capsular  ligament. 


780  LOWER  EXTREMITY. 

EXAETICULATION  OF  THE  FOOT  AT  THE  AnKLE-JOINT   (StMe). 

The  right  foot,  for  example.  The  foot  should  extend  over  the  end  of 
the  table,  and  is  grasped  by  the  operator  with  the  left  hand.  An  in- 
cision is  made  which  commences  npon  the  external  malleolus,  just 
above  its  tip,  and  which  is  carried  straight  downward  and  around  the 
sole  of  the  foot  and  thence  upward  as  far  as  the  tip  of  the  internal 
malleolus;  this  incision  reaches  to  the  bone  throughout  its  course. 
A  second  incision  is  made  which  passes  across  the  front  of  the  ankle- 
joint  through  the  skin,  joining  the  ends  of  the  first  incision. 

Having  incised  the  integument  upon  the  front  of  the  ankle,, 
the  extensor  tendons,  etc.,  are  exposed;  these  are  divided  and  the 
ankle-joint  entered  by  cutting  through  the  anterior  ligament.  In 
doing  this  one  should  not,  by  mistake,  enter  the  joint  between  the 
head  of  the  astragalus  and  the  scaphoid. 

After  the  anterior  ligament  has  been  freely  divided  the  foot  is 
strongly  flexed,  and  then  the  lateral  ligament,  upon  each  side,  is 
divided  close  to  the  bone.  The  joint  now  gapes,  and  while  a  con- 
stantly increasing  traction  is  made  upon  the  foot  the  tendons  of  the 
peronei  are  cut  on  the  outer  side  and  the  tendons  of  the  tibialis 
posticus,  etc.,  on  the  inner  side. 

Cutting  with  the  edge  of  the  knife  close  to  the  bone,  the  os 
calcis  is  then  dissected  out  of  its  bed,  drawing  the  foot  first  to  one 
side  and  then  to  the  other  as  this  dissection  progresses,  and  occa- 
sionally searching  with  the  finger  for  resisting  bands,  etc.,  that  inter- 
fere with  the  enucleation  of  the  bone.  One  should  avoid  button- 
holing the  flap,  especially  as  the  back  part  of  the  os  calcis  is  reached 
and  as  the  attachment  of  the  tendo  Achillis  is  being  separated  from 
the  bone;  the  posterior  tibial  vessels  in  the  inner  side  of  the  flap 
may  also  be  avoided  by  keeping  the  edge  of  the  knife  close  to  the 
bone. 

After  the  os  calcis  has  been  thus  enucleated  from  the  soft  parts 
of  the  heel  and  the  foot  removed,  the  flap  is  turned  up  and  dissected 
away  from  the  lower  margin  of  the  tibia  and  flbula  for  a  short  dis- 
tance, in  order  to  make  way  for  the  application  of  the  saw.  A  thin 
slice  of  the  lower  end  of  the  tibia  and  the  malleoli  are  then  removed. 
The  anterior  tibial  and  the  internal  and  external  plantar  vessels  are 
ligated  and  the  anterior  and  posterior  tibial  nerves  drawn  down  and 
cut  short,  as  are  also  the  ends  of  any  divided  tendons  that  present 
themselves,  and  the  wound  then  closed  with  interrupted  catgut 
sutures. 


AMPUTATIONS,  RESECTIONS,  ETC. 


781 


^^c^ 


Fig.  344.— Right  Foot,  Inner  Side.  A,  astragalus;  C,  os  calcis;  .Sf,  sca- 
phoid; TA,  tendo  Achillis.  Dotted  lines  show  lines  of  section  through  the 
bones  in   Pirogoff's  amputation. 


crrl' 


Fig.  345. — Right  Foot,  Inner  Side.     Dotted  lines  show  section  through 
bones.     Giinther's  modification. 


TA^I     \ 


^^ 


Fig.  346. — Right  Foot,  Inner  Side.     Dotted  lines  show  section  through 
bones.     Le  Fort's  modification. 


782  LOWER  EXTEEMITY. 

If  a  drain  is  used,  this  may  emerge  through  a  small  longitudinal 
incision,  which  is  made  in  the  posterior  part  of  the  flap  upon  the 
outer  side  of  the  tendo  Achillis.  Koenig  recommends  suture  of 
the  divided  anterior  tendons  to  the  edge  of  the  lower,  turned-up 
flap. 

Upon  the  left  foot  the  incision  would  he  made  from  the  tip  of 
the  internal  malleolus  around  the  sole  of  the  foot,  terminating  just 
above  the  tip  of  the  external  malleolus. 

EXAETICULATION  OF  THE  FOOT  AT  THE  AnKLE-JOIXT  (PiEOGOEF)  . 

— The  incisions  are  the  same  as  in  the  preceding  operation — the  S}Tiie. 
After  the  ankle-joint  has  been  freeh'  opened,  the  soft  parts  are 
separated  from  the  astragalus  and  the  os  calcis  backward,  beyond  the 
incision  that  passes  through  the  sole  of  the  foot,  as  far  as  the  poste- 
rior border  of  the  upper  articular  surface  of  the  astragalus.  The 
soft  parts  being  then  retracted,  the  saw  is  applied  to  the  upper  sur- 
face of  the  OS  calcis  and  the  bone  cut  square  through  upon  a  plane  at 
right  angles  to  its  long  axis,  and  corresponding  to  the  incision  that 
passes  through  the  soft  parts  around  the  sole  of  the  foot. 

This  hooded  tegumentary  flap,  which  contains  the  posterior  por- 
tion of  the  OS  calcis,  is  now  separated  from  the  lower  margin  of  the 
tibia  and  fibula,  working  close  to  the  surface  of  the  bones,  and  a 
thin  slice  of  the  lower  end  of  the  tibia,  together  with  both  malleoli, 
then  sawn  off.  This  section  is  made  upon  a  plane  at  right  angles 
to  the  long  axis  of  these  bones. 

The  anterior  tibial  and  the  internal  and  external  plantar  arteries 
are  ligated  and  the  corresponding  nerves  are  drawn  down  and  cut 
short. 

When  the  flap  is  brought  into  position,  the  sawn  surface  of  the 
OS  calcis  and  the  sawn  surface  of  the  tibia  are  apposed;  the  edges 
of  the  wound  are  united  with  interrupted  catgut  sutures. 

If  drainage  is  desired,  it  may  be  provided  by  making  a  small 
longitudinal  opening  in  the  posterior  part  of  the  flap  along  the  outer 
side  of  the  tendo  Achillis.  If  the  traction  of  the  tendo  Achillis  upon 
the  segment  of  the  os  calcis  which  is  left  in  the  flap  is  considerable, 
the  tendon  may  be  divided  subcutaneously. 

Koenig  advises  suture  of  the  ends  of  the  cut  anterior  tendons 
to  the  edge  of  the  tumed-up  flap  to  prevent  these  tendons  retracting 
up  the  leg,  and  also  to  hold  the  flap  in  position. 

The  sawn  surfaces  of  the  bones  are  usually  easily  retained  in 
apposition  by   the  bandage   and   dressings,   especially   if  the   tendo 


AMPUTATIONS,  RESECTIONS,  ETC.  783 

Achillis  has  been  divided.  Some  surgeons  prefer  to  fix  the  segment 
of  the  OS  calcis  to  tlie  lower  end  of  the  tibia  by  driving  a  nail  through 
the  OS  caleis  into  the  lower  end  of  the  tibia. 

Gilnthe/r's  Modification  of  Pirogoff's  Operation. — The  incision 
across  the  front  of  the  ankle  is  tlie  same  as  in  the  previous  opera- 
tion ;  the  lower  incision,  which  passes  through  the  sole  of  the  foot, 
instead  of  passing  vertically  downward  is  directed  obliquely  down- 
ward and  forward;  upon  the  inner  side  of  the  foot  this  incision  passes 
just  behind  the  tubercle  of  the  scaphoid,  and  a  similar  obliquity  is  also 
observed  upon  the  outer  side  of  the  foot,  the  incision  striking  just 
behind  the  tuberosity  of  the  base  of  the  fifth  metatarsal.  The  soft 
parts  are  dissected  back,  away  from  the  bones,  for  a  short  distance,  and, 
as  in  the  previous  operation,  the  ankle-joint  is  freely  opened  and  the 
saw  applied  to  the  upper  surface  of  the  os  calcis  behind  the  astragahis 
and  the  os  calcis  sawn  through,  not  straight  down  as  in  the  Pirogofi', 
but  obliquely  downward  and  forward  so  as  to  end  just  behind  the  an- 
terior edge  of  the  lower  surface  of  the  os  calcis. 

The  soft  parts  are  then  separated  from  the  lower  ends  of  the  tibia 
and  fibula,  and,  being  well  retracted,  the  lower  ends  of  these  bones 
are  sawn  off  obliquely  from  behind  forward  and  downward. 

The  sawn  surface  of  the  os  calcis  is  now  applied  to  the  sawn  sur- 
face of  the  tibia  without  any  rotation,  and  thus  division  of  the  tendo 
Achillis  is  avoided,  and,  further,  that  part  of  the  stump  which  sup- 
ports the  weight  and  is  applied  to  the  ground  corresponds  to  the  under 
surface  of  the  os  calcis  and  the  integument  covering  it. 

After  the  vessels  have  been  ligated  the  edges  of  the  wound  are 
brought  together  with  interrupted  catgut  sutures.  It  may  be  wise  to 
fix  the  stump  of"  the  os  calcis  to  the  lower  surface  of  the  tibia  with  a 
nail,  which  is  driven  through  the  os  calcis  into  the  lower  end  of 
the  tibia,  previously  making  a  small  incision  in  the  skin  to  allow  the 
nail  to  be  introduced.  Drainage  may  be  provided  as  in  the  preceding 
operations. 

Le  Fort's  Modification  of  Pirogoffs  Amputation. — A  slightly 
curved  dorsal  incision  is  made  across  the  foot,  corresponding  to  the 
Chopart  joint,  commencing  on  the  outer  side  of  the  foot  one  inch 
below  and  in  front  of  the  tip  of  the  external  malleolus  and  ending  on 
the  inner  side  of  the  foot  at  the  tubercle  of  the  scaphoid.  A  second 
incision,  passing  obliquely  forward,  is  made  through  the  sole  of  the 
foot  as  in  Giinther's  operation,  uniting  the  ends  of  the  dorsal  in- 


784  LOWER  EXTREMITY. 

cision.  The  integument  is  then  dissected  back,  and  the  ankle-joint, 
Tinder  forcible  flexion,  widely  opened  as  in  the  Pirogoff. 

The  upper  third  of  the  os  calcis,  through  a  plane  parallel  with 
the  long  axis  of  the  bone,  is  sawn  off;  this  section  through  the  os 
calcis  commences  at  the  posterior  end  of  the  bone,  after  first  sepa- 
rating the  soft  parts  and  the  tendo  Achillis  sufficiently  to  apply  the 
saw,  and  passes  forward  through  the  bone  as  far  as  the  Chopart 
joint  (articulation  between  the  os  calcis  and  cuboid).  The  foot  is 
then  removed,  leaving  the  remains  of  the  os  calcis,  with  the  tendo 
Achillis  attached,  in  the  flap.  The  lower  ends  of  the  tibia  and  fibula, 
after,  proper  separation  and  retraction  of  the  soft  parts,  are  then 
sawn  off.  The  sawn  surfaces  are  apposed  and  the  wound  closed.  This 
is  a  rather  difficult  operation  to  perform. 

Amputation  of  the  Leg. — The  leg  may  be  amputated  at  any  point 
up  to  the  level  of  the  tuberosity  of  the  tibia.  With  a  view  to  the  use 
of  an  artificial  limb,  one  should  make  an  effort  to  save  the  knee-joint 
and  as  much  of  the  length  of  the  leg  as  possible. 

In  amputating  the  leg  we  may  use  fla]3s  of  different  length,  a 
long  anterior  and  a  short  posterior,  or  the  reverse,  and  the  flaps  may 
consist  of  the  integument  only  or  may  include  the  muscular  tissue  as 
well.  The  circular  method  may  also  be  used  here,  a  flap  of  integument 
being  turned  back  like  a  cuff  to  the  point  where  the  muscle  and  bone 
are  to  be  divided,  and  if  necessary,  owing  to  the  bulging  of  the  muscles 
of  the  calf,  the  circular  tegumentary  flap  may  be  split,  on  one  or  both 
sides,  in  order  to  facilitate  its  reflection. 

It  seems  to  me  that  lateral  skin-flaps  of  equal  length,  cut  in  such 
fashion  as  to  bring  the  suture  line  behind  the  end  of  the  bone,  is 
the  preferable  operation, — the  so-called  lateral  hooded  flap, — ^yet  we 
should  not  commit  ourselves  to  any  particular  method,  but  take  the 
flaps  as  best  we  can  when,  thereby,  more  of  the  length  of  the  limb 
can  be  saved. 

Amputation  of  the  Leg  with  Lateeal  Hooded  Flaps. — The 
tourniquet  is  placed  above  the  knee.  The  patient  lies  with  the  leg  pro- 
jecting over  the  end  of  the  table  and  steadied  by  an  assistant,  who 
grasps  it  by  the  foot  and  elevates  it.  We  must  flrst  decide  upon  the 
point  at  which  the  bones  are  to  be  divided,  and  then  make  our  flaps  ac- 
cordingly (see  Fig.  348).  The  incision  is  commenced  on  the  front  of 
the  limb,  one  and  one-half  inches  below  the  level  at  which  the  bones  are 
to  be  divided  and  just  to  the  outer  side  of  the  sharp  anterior  border 
of  the  tibia ;  from  this  point  the  incision  curves  downward  and  back- 


AMPUTATIONS,  RESECTIONS,  ETC. 


'85 


ward  around  either  side  of  the  leg,  approaching  tlic  middle  line  on 
the  posterior  aspect  of  the  limb,  where  it  is  carried  upward,  in  the 
middle  line,  to  a  point  opposite  the  level  at  which  the  bones  are  to  be 
divided.  This  incision  extends  through  the  skin  and  subcutaneous  fat 
down  to,  but  not  including,  the  deep  fascia. 

Each  of  the  lateral  flaps  thus  marked  out  should  correspond  in 
length  to  half  the  thickness  of  the  limb,  adding  one-third  to  allow 


Fig.  347. — Amputation  of  Leg.     Hooded  flap  of  skin  and  fat  turned  back. 
Arrow  shows  level  at  which  bones  are  to  be  divided. 


for  retraction.     The  lengih  of  the  flap  is  measured  from  the  level 
at  which  the  bones  are  to  be  divided. 

The  edge  of  the  flap  is  seized  with  the  fingers,  and,  making 
strong  traction,  it  is  separated  from  the  deep  fascia,  taking  all  the 
subcutaneous  fat  with  it  and  cutting  with  long  sweeps  of  the  knife, 
its  edge  being  always  directed  toward  the  deep  fascia  in  order  to 
avoid  cutting  the  small  vessels  that  ramify  in  the  fat  and  supply  the 
integimient.  In  reflecting  the  flap  we  should  work  evenly  around 
the  whole  circumference  of  the  limb. 


786  LOWER  EXTREMITY. 

After  the  flaps  liave  been  turned  back  as  far  as  the  level  at 
which  the  bones  are  to  be  sawn  through,  and  while  they  are  thus  held 
by  an  assistant,  the  muscles  are  divided  with  a  long  knife,  down  to 
the  bone,  with  one  clean,  circular  sweep.  The  muscular  tissue  be- 
tween the  bones  may  be  divided  with  a  narrow,  double-edged  knife 
or  Avith  a  scalpel  and  the  periosteum  then  incised  to  make  way  for 
the  saw. 

The  heel  of  the  saw  is  firmly  placed  upon  the  edge  of  the  tibia 
and,  drawing  back,  a  groove  is  made  in  which  the  saw  works  easily. 
When  the  tibia  is  partly  sawn  through  the  fibula  may  be  engaged 
in  order  to  complete  the  division  of  both  bones  simultaneously. 

The  use  of  the  three-tailed  cloth  retractor  may  be  dispensed 
with,  as  the  assistant  can  better,  with  his  hands  or  Avith  sharp  re- 
tractors, hold  the  divided  muscles  out  of  the  way  of  the  saw. 

While  the  bones  are  being  sawn  the  limb  is  supported  below, 
that  its  weight  may  not  prematurely  break  the  bones  before  their 
section  with  the  saw  has  been  completed. 

The  prominent  anterior  angle  of  the  tibia  may  be  sawn  off  or 
chiseled  away,  although  this  is  probably  an  unnecessary  step,  espe- 
cially if  the  flaps  are  sufficiently  long.  The  end  of  the  flbula  may 
be  cut  a  little  shorter  with  the  bone-forceps.  '  In  shortening  the 
fibula  one  should  not  use  the  straight  bone-forceps,  as  they  rather 
crush  and  splinter  the  shaft  of  the  bone;  it  is  better  to  do  this  by 
taking  several  bites  with  a  sharp  rongeur. 

Before  removing  the  tourniquet  the  anterior  and  posterior 
tibial  vessels  are  clamped  and  tied.  The  anterior  tibial  is  found 
upon  the  front  of  the  interosseous  membrane  between  the  bones; 
the  anterior  tibial  nerve  may  be  pulled  down  and  cut  short  at  the 
same  time.  The  posterior  tibial  vessels  are  located  in  the  back  of 
the  stump,  on  the  tibial  side  of  the  leg,  beneath  the  gastrocnemius 
and  soleus  muscles;  the  large  nerve  which  accompanies  these  vessels 
may  be  pulled  down  and  cut  short.  The  peroneal  branch  of  the 
posterior  tibial  artery,  which  is  found  just  behind  the  fibula,  should 
also  be  tied.  After  the  tourniquet  has  been  removed,  any  remaining 
vessels  that  bleed  may  be  caught  and  tied.  The  edges  of  the  flaps 
are  joined  with  interrupted  catgut  sutures,  leaving  a  drain  which 
emerges  posteriorly.  When  the  suture  is  complete,  it  will  be  seen 
that  the  suture  line  is  located  behind  the  end  of  the  tibia  and  thus 
out  of  the  way  of  pressure. 


AMPUTATIONS,  RESECTIONS,  ETC.  787 

Surgical  Anatomy  of  the  Knee-joint. — The  knee-joint  is  made 
up  of  the  lower  end  of  the  femur  and  the  upper  end  of  the  tibia  and 
the  patella.  The  lower  end  of  the  femur  is  expanded  and  rather 
cuboidal  in  form,  having  two  prominent  condyles  which  project  back- 
M-ard  beyond  the  posterior  surface  of  the  shaft  of  the  bone. 

The  inner  condyle,  when  the  femur  is  held  perpendicularly,  is 
seen  to  extend  lower  than  the  outer  and  is  also  rather  narrower  than 
the  outer.  The  inferior  and  posterior  surfaces  of  the  condyles  are 
smooth,  rounded,  and  covered  with  cartila.se ;  this  smooth  articular 
surface  is  also  continued  upward  upon  the  anterior  surface  of  the 
lower  end  of  the  femur,  extendino-  'rather  higher  externally  than 
internall}^,  and  is  limited  externally  by  a  prominent  ridge. 

Behind,  between  the  projecting  condyles,  there  is  a  space  large 
enough  to  accommodate  the  thumb,  known  as  the  intercondyloid 
notch;  to  the  contiguous  surfaces  of  this  notch  the  crucial  ligaments 
are  attached. 

The  inner  condyle  presents  upon  its  inner  surface  a  broad  promi- 
nence, the  inner  tuberosity,  and  to  this  the  internal  lateral  ligament 
is  attached. 

The  outer  condyle  presents  upon  its  outer  surface  a  prominent 
tubercle,  which  is  located  a  little  behind  the  center,  and  to  this  is 
attached  the  external  lateral  ligament.  Immediately  below  this  tu- 
bercle there  is  a  smooth  groove  in  which  the  tendon  of  the  popliteus 
muscle  is  lodged. 

The  lower  and  posterior  portions  of  the  articular  surface  of  the 
condyles  articulate  with  the  articular  surface  of  the  tibia:  the  ante- 
rior portion  articulates  with  the  patella.  The  relation  of  these 
articular  surfaces  varies  according  to  the  position  of  the  knee-joint. 
The  upper  end  of  the  tibia  presents  a  superior  surface,  which 
is  divided  into  two  lateral  concave,  rather  ovoidal  portions,  which 
articulate  with  the  condyles  of  the  femur,  and  an  intermediate  rough 
area  which  is  marked  by  a  prominence,  the  spinous  process,  the  sum- 
mit of  which  presents  two  prominent  tubercles  for  the  attachment 
of  the  extremities  of  the  semilunar  interarticular  fibro-cartilages. 
This  intermediate  space,  in  front  and  behind  the  spinous  process,  is 
rough  for  the  attachment  of  the  semilunar  cartilages  and  the  crucial 
ligaments. 

The  anterior  surface  of  the  upper  end  of  the  tibia  presents  a 
triangular  surface,  its  base  corresponding  to  the  anterior  border  of 
the  upper  surface  of  the  tibia  and  its  apex  to  the  tuberosity  of  the 


788  LOWER  EXTREMITY. 

tibia.  The  tuberositj^  of  the  tibia  gives  attachment  to  the  liga- 
mentum  patellge. 

The  patella  presents  a  smooth  posterior  surface,  covered  with 
cartilage,  which  articulates  with  different  parts  of  the  articular  sur- 
face of  the  condyles  in  different  positions  of  the  knee-joint. 

The  upper  and  lateral  borders  of  the  patella  give  attachment  to 
the  expanded  tendon  of  the  quadriceps;  the  lower  part  of  the  poste- 
rior surface,  which  is  rough,  gives  attachment  to  the  ligamentum 
patellae.  This  ligament,  which  is  attached  below  to  the  tubercle  of 
the  tibia,  fixes  the  patella  to  this  bone. 

The  anterior  surface  of  the  patella  is  smooth  and  is  covered  by 
a  fibrous  expansion  from  the  quadriceps  extensor,  and  is  separated 
from  the  integument  by  a  bursa  which,  at  times,  becomes  inflamed — 
housemaid's  knee. 

The  knee  is  provided  with  a  capsular  ligament  which  is  thin  or 
wanting  in  places,  and  is  strongly  reinforced  by  expansions  derived 
from  the  deep  fascia  (lata)  and  from  the  quadriceps  and  by  various 
accessory  ligaments. 

In  front  is  the  ligamentum  patellge.  Behind  is  the  ligament  of 
Winslow,  which  forms  the  posterior  part  of  the  capsule;  this  liga- 
ment is  strong,  and  extends  between  the  femur  and  the  tibia  and  is 
strengthened  by  bands  from  the  tendon  of  the  semimembranosus, 
which  pass  upward  and  outward  from  the  inner  tuberosity  of  the 
tibia  to  the  external  condyle  of  the  femur;  it  forms  part  of  the  floor 
of  the  popliteal  space,  and  the  popliteal  vessels  lie  close  to  it. 

The  origins  of  the  gastrocnemius,  plantaris,  and  popliteus  mus- 
cles are  intimately  connected  with  the  posterior  ligament. 

Laterally,  upon  the  innet  side  of  the  joint,  we  have  the  in- 
ternal lateral  ligament,  which  extends  from  the  tuberosity  of  the 
internal  cond3de  to  the  upper  part  of  the  internal  bordei'  of  the 
tibia,  and  upon  the  outer  side  the  external  lateral  ligament,  which 
is  attached  above  to  the  tubercle  on  the  external  condjde  and  below 
to  the  head  of  the  fibula.  These  lateral  ligaments  are  attached  be- 
hind the  center  of  the  condyles,  and  are  therefore  put  upon  the 
stretch  by  any  attempt  at  overextension  of  the  knee-joint.  The  cap- 
sule is  further  reinforced,  on  the  sides,  by  the  broad  expansions  that 
are  derived  from  the  quadriceps  extensor  and  the  fascia  lata;  these 
are  attached  to  the  sides  of  the  patella. 

Within  the  joint  are  the  ligamenta  alaria,  which  are  simply 
redundant  folds  of  the  synovial  membrane  that  are  reflected  from 


AMPUTATIONS,  RESECTIONS,  ETC.  789 

the  sides  of  the  patella;  these  are  prolonged  downward  and  back- 
ward as  the  ligamentum  mucosum,  which  is  attached  behind  to  the 
femur  in  the  intercondyloid  notch  between  the  condyles. 

The  crucial  ligaments,  two  in  number,  pass  between  the  lower 
end  of  the  femur  and  upper  surface  of  the  tibia,  crossing  one  an- 
other, and  help  to  fix  the  bones.  The  internal  passes  from  tlie  outer 
side  of  the  internal  condyle  downward,  backward,  and  outward,  and 
is  attached  to  the  rough  portion  of  the  upper  surface  of  the  tibia 
behind  the  spine.  The  external  extends  from  the  inner  side  of  the 
external  condyle  downward,  forward,  and  inward  and  is  attached  to 
the  rough  space  in  front  of  the  spine  of  the  tibia. 

Within  the  joint,  interposed  between  the  articular  surfaces  of 
the  femur  and  tibia,  are  the  two  semilunar  fibro-cartilages,  the  in- 
ternal and  the  external.  Placed  upon  the  upper  surface  of  the  tibia, 
they  serve  to  deepen  the  concavity  which  receives  the  articular  sur- 
face of  the  femur.  They  are  semilunar  in  form,  and  are  attached 
by  their  borders  to  the  margin  of  the  upper  surface  of  the  tibia  and 
to  the  inner  contiguous  surface  of  the  capsule ;  by  their  extremities 
they  are  attached  to  the  rough  middle  portion  of  the  upper  surface 
of  the  tibia  between  the  two  articular  surfaces. 

The  synovial  membrane  of  the  knee-joint  is  very  extensive ;  it 
lines  the  inner  surface  of  the  capsule  and  gives  off  a  large  pouch, 
which  extends  upward  upon  the  front  of  the  femur  beneath  the 
quadriceps  extensor;  as  the  ligamenta  alaria,  the  synovial  membrane 
is  reflected  from  the  sides  of  the  patella  and  is  continued  backward 
as  a  process,  the  ligamentum  mucosum,  to  the  back  of  the  femur, 
between  the  two  condyles,  where  it  is  attached.  The  synovial  mem- 
brane lines  both  surfaces  of  the  semilunar  cartilages  and  invests  the 
crucial  ligaments,  and  often  communicates  with  the  synovial  lining 
of  the  tibio-fibular  joint  and  with  the  bursse  adjacent  to  the  knee- 
joint.  It  gives  a  process  externally  which  is  found  between  the 
margin  of  the  external  semilunar  cartilage  and  tendon  of  the  pop- 
liteus  muscle,  forming  a  bursa  for  this  tendon.  A  pad  of  fat  is 
wedged  into  the  joint  below  the  patella,  being  covered  by  the  syno- 
vial membrane  of  the  joint  and  prolonged  into  the  ligamentum 
mucosum. 

The  Burs^  Adjacent  to  the  Knee-joint. — The  arrangement 
of  the  bursas  about  the  knee-joint  is  somewhat  irregular. 

Posteriorly.     On  the  outer  side:     First.     Between  the  posterior 


790  LOWER  EXTREMITY. 

part  of  the  capsule  and  the  outer  head  of  the  gastrocnemius  there 
is  a  bursa  which  sometimes  communicates  with  the  joint. 

Second.  Beneath  the  tendon  of  the  popliteus  there  is  a  bursa 
which  ahvays  communicates  witli  the  joint. 

Third.  Occasionally  there  is  a  bursa  between  the  tendon  of 
the  popliteus  and  the  external  lateral  ligament. 

Inner  side :  First.  Between  the  inner  head  of  the  gastrocnemius 
and  the  posterior  part  of  the  capsule  there  is  a  bursa  which  often 
communicates  with  the  joint  and  sends  a  process  between  the  gas- 
trocnemius and  the  semimembranosus. 

Second.  Between  the  semimembranosus  and  the  head  of  the 
tibia. 

Third.  Occasionally  between  the  tendons  of  the  semitendinosus 
and  semimembranosus. 

Anteriorly.  Fii'st.  Between  the  anterior  surface  of  the  patella 
and  the  integument. 

Second.  Between  the  ligamentum  patellae  and  anterior  surface 
of  the  tibia  (tubercle  tibije). 

EXARTICUIATION    OF    THE    LeG    AT    THE    KnEE- JOINT    (STEPHEN 

Smith  Hooded  Flap). — The  patient  lies  upon  his  back,  with  the  leg 
overhanging  the  end  of  the  table.  One  should  remember  that  the  end 
of  the  femur  is  large  and  that  a  considerable  flap  is  required  to  cover 
it.    The  tourniquet  is  placed  above  the  knee,  high  up. 

The  incision,  which  passes  through  the  integument  and  fat  down 
to  the  deep  fascia,  commences  in  front,  one  inch  below  the  tubercle 
of  the  tibia ;  from  this  point  it  curves  downward  and  backward  across 
either  side  of  the  leg,  and  behind,  near  the  middle  line,  is  carried 
upward  into  the  popliteal  space  as  high  as  the  level  of  the  knee- 
joint.  Two  lateral  flaps  with  rounded  corners  are  thus  marked  out. 
One  should  avoid  making  the  flap  scant  by  getting  well  upon  the 
posterior  aspect  of  the  leg  before  turning  the  incision  upward  into 
the  popliteal  space. 

This  tegumentary  flap,  which  includes  the  subcutaneous  fat,  is 
now  seized  with  the  fingers  and  dissected  away  from  the  deep  fascia 
with  long  sweeps  of  the  knife,  its  edge  being  directed  toward  the 
deep  fascia  so  as  not  to  cut  into  the  flap.  Considerable  traction  should 
be  applied  to  the  flap  as  it  is  being  reflected,  in  order  to  facili- 
tate its  separation  from  the  deep  fascia.  The  flap  should  be  dis- 
sected up  to  the  level  of  the  joint  all  around.  While  the  flap  is 
retracted  the  knee-joint  is  shar|3ly  flexed  and  entered,  cutting  first 


AMPUTATIONS,  RESECTIONS,  ETC.  791 

through  the  lower  part  of  the  ligamentiim  patella^;  the  bhide  of  the 
knife  is  then  introduced,  flatwise,  between  the  semilunar  fibro-carti- 
lages  and  the  upper  surface  of  the  tibia,  and  the  cartilages  separated 


Fig.  348.— Right  Leg,  Outer  Side.  A,  outline  of  hooded  skin  flap  in  am- 
putation of  the  leg.  Dotted  line  shows  line  of  division  through  bones.  B, 
outline  of  skin  flap  in  Stephen  Smith  hooded  flap  for  exarticulation  at  the 
knee-joint. 

all  around  from  the  edge  of  the  upper  surface  of  the  tibia,  so  that 
they  may  be  left  attached  in  the  stump  after  the  leg  has  been  am- 
putated. 


793  LOWER  EXTREMITY. 

The  lateral  ligaments  are  cut  on  each  side^  and  with  the  limb 
still  strongly  flexed  the  attached  ends  of  the  fibro-cartilages  and  the 
crucial  ligaments  are  cut  away  from  the  upper  surface  of  the  tibia, 
and  then,  with  a  long  knife,  the  soft  parts  behind  the  joint,  the 
posterior  ligament,  popliteal  vessels,  etc.,  and  tendons  and  muscle, 
are  cut  square  through  from  within  the  joint.  The  amputation  is 
thus  complete. 

The  popliteal  artery  and  its  vein,  which  lies  upon  (superficial 
to)  it,  are  each  seized  and  tied.  They  lie  close  to  the  posterior  sur- 
face of  the  femur.  The  popliteal  nerves  are  pulled  down  and  cut 
short.  The  edges  of  the  flap  are  united  with  interrupted  catgut  su- 
tures, a  space  being  left  posteriorly  for  drainage. 

This  operation  gives  us  a  good,  broad,  fairly  flat  stump,  with 
the  suture  line  behind  the  extremity  of  the  bone.  The  reason  for 
leaving  the  fibro-cartilages  in  the  stump  is  that  they  tend  to  make  a 
better  base  to  the  end  of  the  femur. 

Teanscondylar  Amputation  at  the  Knee-joint  (Garden)  . — 
A  long  anterior  and  a  short  posterior  flap  are  made,  the  femur  being 
divided  through  the  condyles.  Both  legs  hang  over  the  end  of  the 
table,  the  one  to  be  amputated  being  extended  and  supported  by  an 
assistant,  who  grasps  the  foot.  In  amputating  the  right  limb  the 
operator  stands  on  the  outer  side  of  the  leg  and  with  the  thumb  and 
forefinger  indicates  the  points  at  which  the  incision  commences  and 
ends. 

A  long  anterior  flap  is  marked  out  by  an  incision  which  passes 
through  the  skin  and  subcutaneous  fat  down  to  the  deep  fascia. 
This  incision  commences  at  a  point  a  little  behind  the  middle  of 
the  internal  condyle  and  upon  a  level  with  the  knee-joint;  it  passes 
down  the  inner  side  of  the  leg  as  far  as  the  tubercle  of  the  tibia, 
swings  outward  across  the  front  of  the  leg,  passing  below  the  tubercle 
of  the  tibia,  and  is  then  carried  upward  upon  the  outer  side  of  the 
leg  to  a  point  upon  the  outer  condyle  opposite  that  at  which  the 
incision  began  upon  the  inner  cond3rle. 

In  operating  upon  the  left  leg  the  operator  may  stand  upon  the 
inner  side  of  the  limb,  making  the  incision  from  the  outer  condyle 
around  to  the  inner.  The  corners  of  the  flap  should  be  rounded,  but 
the  flap  should  not  be  tongue-shaped. 

The  edge  of  the  anterior  flap  is  seized  with  the  fingers,  and  the 
flap,  consisting  of  the  skin  and  subcutaneous  fat,  is  dissected  away 
from  the  deep  fascia  and  reflected  as  far  as  the  lower  border  of  the 


AMPUTATIONS,  RESECTIONS,  ETC. 


'93 


patella ;   in  thus  detaching  the  tegumentary  flap  the  edge  of  the  knife 
should  always  be  directed  toward  the  deep  fascia.     The  knee  is  then 


Fig.  349. — Right  Leg.     Garden's  Amputation.     Solid  line  indicates  flaps. 
Dotted  line  shows  line  of  division  through  the  condyle. 

flexed  and  the  joint  opened  from  in  front  with  the  long  knife,  which 
first  divides  the  ligamentum  patellse  and  then  passes  straight  through 


Fig.  350. — Stump  After  Garden's  Amputation. 

the  joint,  cutting  capsule,  lateral  ligaments,  and  crucial  ligaments, 
and  emerging  through  the  structures  in  the  popliteal  space;  as  the 
knife  passes  through  the  integument  in  the  popliteal  space  the  assist- 


794  LOWER  EXTREMITY. 

ant  should  draw  the  soft  parts  upward  toward  the  hip,  and  the  knife 
nia}^  be  turned  somewhat  downward  in  order  that  the  posterior  flap 
may  not  be  cut  too  short,  as  the  integument  in  this  region  tends  to 
Tetract  very  much. 

The  soft  parts  are  then  separated  about  the  circumference  of  the 
condyles  and  retracted,  and  the  saw  applied,  the  section  being  made, 
not  above,  but  directly  through,  the  cond3des  proper.  The  sharp 
edge  of  the  sawn  surface  of  the  condyles  may  be  rounded  off  somewhat 
^ith  a  file  or  with  a  rongeur  bone-forceps.  The  popliteal  artery  and 
vein  are  found  posterior  to  the  bone,  and  should  be  tied  separately 
and  the  popliteal  nerves  drawn  down  and  cut  short. 

The  stump  is  covered  over  by  Joining  the  edges  of  the  long  ante- 
rior skin-flap  and  the  short  posterior  flap  with  interrupted  catgut  su- 
tures. It  is  wise  to  drain  the  synovial  pouch,  which  is  located  in  front 
of  the  lower  end  of  the  femur,  imder  the  quadriceps  extensor,  by  in- 
troducing two  tubes,  which  reach  well  up  into  the  pouch,  emerging 
through  the  incision  on  either  side. 

Amputatiox  at  the  Knee-joint  (Gritti-Stokes). — The  posi- 
tion of  the  patient  is  the  same  as  described  in  Garden's  amputation.  A 
long  anterior  flap  is  marked  out  by  an  incision  commencing  upon  the 
internal  condyle  just  behind  its  middle,  andrpassing  down  the  side  and 
then  across  the  front  of  the  leg  just  below  the  tubercle  of  the  tibia, 
and  thence  upward  to  a  point  on  the  outer  condyle  a  little  behind  its 
center.  The  flap  thus  outlined  is  like  the  Garden,  but  somewhat 
shorter.  The  edge  of  this  anterior  flap  is  seized  with  the  fingers  and, 
including  all  the  subcutaneous  fat,  is  separated  from  the  deep  fascia, 
cutting  with  the  edge  of  the  knife  directed  toward  the  deep  fascia  and 
constantly  making  considerable  traction  upon  the  flap.  At  the  lower 
border  of  the  patella,  the  flap  being  retracted  and  the  leg  flexed,  the 
knee-joint  is  opened  from  before  backward,  cutting  with  the  long  knife 
through  the  ligamentum  patellae,  capsule,  and  lateral  and  crucial  liga- 
ments, and  finally  through  the  posterior  ligaments  and  the  parts  in 
the  popliteal  space.  While  cutting  through  the  integument  in  the  pop- 
liteal space  the  skin  should  be  drawn  well  upward  toward  the  hip-joint 
so  that  the  posterior  flap  may  not  be  cut  too  short.  There  should  be 
a  short  posterior  flap,  one-half  to  one  inch  long. 

The  soft  parts  are  separated  from  the  lower  end  of  the  femur, 
working  with  the  edge  of  the  knife  close  to  the  bone,  to  a  point  beyond 
the  upper  limits  of  the  articular  surface;  here  a  circular  cut  is  made 
around  the  bone,  and  with  the  saw  the  enid  of  the  femur  is  removed 


AMPUTATIONS,  RESECTIONS,  ETC. 


795 


parallel  with  the  plane  of  its  inferior  articular  surface.  i\.fter  the 
articular  end  of  the  femur  has  been  removed,  the  patella,  being 
surrounded  by  a  towel  to  give  a  good,  firm  grip,  is  seized  with  the  left 
hand  and  the  whole  of  its  articular  surface  sawn  off.  The  sawn  sur- 
face of  the  patella  is  then  apposed  to  that  of  the  lower  end  of  the 
femur,  to  which  it  is  fixed  by  two  chromicized  catgut  sutures,  which 
are  passed  through  drill  holes  in  the  posterior  edge  of  the  femur  and 
the  lower  border  of  the  patella.  The  patella  may  also  be  fixed  to  the 
femur  by  a  nail  driven  through   it   into   the  femur.     The  popliteal 


-Gritti-Stokes  Amputation.     Solid  lines  indicate  flaps, 
lines  show  section  through  femur  and  patella. 


Dotted 


vessels  require  ligation.  A  tube  may  be  introduced  on  each  side 
to  drain  the  large  synovial  space  under  the  quadriceps  extensor  ten- 
don. The  edges  of  the  wound  are  sutured  with  interrupted  stitches  of 
catgut. 

Amputation  of  the  Thigh. — As  a  rule,  this  is  accomplished  by 
a  modified  circular  in  two — or,  better,  three — steps,  the  skin  being 
divided  upon  one  level,  the  muscles  upon  another,  and  the  bone  upon 
a  third.  A  tourniquet  is  placed  about  the  limb,  high  up,  near  the 
hip-joint. 

The  thigh  should  hang  over  the  end  of  the  table.  For  either  the 
right  or  the  left  thigh  it  is  probably  more  convenient  for  the  operator 
to  stand  upon  its  outer  side.    An  assistant  steadies  the  thigh  by  grasp- 


796  LOWER  EXTREMITY. 

iiig  it  above  and  drawing  the  integimient  a  little  toward  the  hip.  A 
second  assistant  may  support  the  limb  below. 

The  point  at  which  the  bone  is  to  be  divided  is  first  located,  and 
then,  with  a  sweep  of  the  long  amputating  knife,  a  circular  incision 
is  made  around  the  limb  through  the  skin  and  fat  down  to  the  deep 
fascia,  thus  marking  the  lower  limits  of  the  skin-flap.  This  circular 
incision  in  the  skin  should  be  placed  below  the  point  at  which  the 
bone  is  to  be  divided  a  distance  equal  to  half  the  diameter  of  the  limb 
at  that  point  (where  the  bone  is  to  be  divided),  adding  one-third 
more  to  allow  for  retraction. 

The  edge  of  the  skin-flap  is  seized  with  the  fingers  and  the  flap 
reflected  like  a  cufl,  separating  it  from  the  underlying  deep  fascia 
with  long  sweeps  of  the  scalpel,  its  edge  being  always  directed  toward 
the  deep  fascia  in  order  to  avoid  cutting  into  the  flap.  While  the 
flap  is  being  dissected  away  from  the  deep  fascia,  upon  the  posterior 
aspect  of  the  thigh,  the  limb  may  be  elevated  by  the  assistant. 

After  the  flap  has  been  dissected  back  to  within  one  inch  of  the 
point  at  which  the  bone  is  to  be  divided,  the  long  knife  is  again  taken 
and  the  muscles  are  cut,  with  a  circular  sweep,  down  to  the  bone. 
The  muscular  tissue  is  then  scraped  back  away  from  the  bone  with 
a  blunt  instrument  as  far  as  the  point  at  which  the  bone  is  to  be 
divided.  While  the  assistant  retracts  the  skin  and  muscles  with  his 
hands  or  sharp  retractors,  a  circular  incision  is  made  through  the 
periosteum  around  the  bone,  and  then,  planting  the  heel  of  the  saw 
upon  the  bone,  it  is  drawn  firmly  backward,  thus  making  a  groove 
for  itself,  and  the  bone  is  then  quickly  severed;  the  assistant  sup- 
ports the  limb  lightly  below  in  order  that  the  bone  may  not  be 
broken  before  it  is  sawn  completely  through.  The  limb  should  not 
be  so  held  by  the  assistant  as  to  jam  the  saw. 

The  femoral  and  profunda  femoris  arteries  and  veins,  which  are 
located  close  to  the  inner  side  of  the  femur,  are  tied  separatel}^,  and 
the  tourniquet  then  removed,  after  which  any  remaining  bleeding 
points  may  be  clamped  and  tied. 

While  seeking  these  bleeding  points  only  a  limited  part  of  the 
surface  of  the  stump  need  be  exposed  at  one  time,  the  rest  being 
covered  and  compressed  with  a  hot  gauze  pad.  The  chief  bleeding 
points  are  sought  between  the  muscles.  The  sciatic  nerve,  which  is 
found  between  the  muscles  on  the  back  of  the  thigh,  is  pulled  down 
and  cut  short. 

The  edges  of  the  flap  are  brought  together  from  side  to  side. 


AMPUTATIONS,  RESECTIONS,  ETC.  797 

making  a  transverse  line,  with  interrupted  catgut  sutures.  It  is 
usually  wise  to  leave  a  drain  for  several  days.  If  the  subject  is  very 
muscular  and  the  limb  very  thick,  it  may  be  necessary  to  incise  the 
flap  on  one  side  in  order  to  facilitate  its  reflection. 

This  is  probably  the  preferable  method  of  amputating  the 
thigh.  Instead  of  the  above  descrilied  method,  one  may  use  a  long 
anterior  and  a  correspondingly  shorter  posterior  tegumentary  flap, 
or  flaps  which  include  all  the  muscle  clown  to  the  bone  as  well  as  the 
skin  may  be  used. 

Surgical  Anatomy  of  the  Hip-joint. — The  hip-joint  is  composed 
of  the  upper  end  of  the  femur  and  the  acetabular  cavity  of  the  os 
innominatum. 

The  upper  end  of  the  femur  presents  a  rounded  head  which 
represents  about  two-thirds  of  a- sphere;  it  is  smooth,  covered  with 
cartilage,  and  is  marked  in  the  apex  of  its  posterior,  inferior  quad- 
rant by  a  depression  in  which  is  attached  the  ligamentum  teres.  The 
head  of  the  femur  is  directed  upward,  inward,  and  forward. 

The  head  of  the  femur  is  joined  to  the  shaft  by  the  neck,  which 
passes  from  the  head  downward  and  outward  to  the  shaft;  the  neck 
is  somewhat  flattened  from  before  backward,  and  is  broader  at  its 
junction  with  the  shaft  than  with  the  head,  and  is  narrowest  mid- 
way between  these  points. 

The  upper  end  of  the  shaft  presents  upon  its  outer  aspect  the 
great  trochanter,  a  prominent,  square-shaped  mass  of  bone.  The 
external  surface  of  the  great  trochanter  is  continuous  with  the  ex- 
ternal surface  of  the  shaft,  and  is  marked  by  a  rough  line  that  passes 
obliquely  from  above  downward  and  forward;  to  this  line  is  attached 
the  gluteus  medius  muscle;  the  smooth  surface  below  and  behind 
this  line  is  covered  by  the  gluteus  maximus,  a  bursa  being  inter- 
posed. 

The  inner  surface  of  the  trochanter  is  applied  to  the  shaft  of 
the  bone,  except  for  its  upper,  posterior  part,  which  is  free  and 
hollowed  out  to  form  the  digital  fossa;  here  the  tendon  of  the 
obturator  externus  is  attached,  and  this  attachment  must  be  sepa- 
rated before  one  can  dislocate  the  head  of  the  femur  l3ackward  in 
doing  a  resection  of  the  hip-joint. 

The  prominent  upper  border  of  the  great  trochanter  is  free, 
and  gives  attachment  to  the  tendons  of  the  obturator  internus  and 
gemelli  in  front  and"  to  the  tendon  of  the  pyriformis  behind.  The 
anterior  border   of   the   trochanter   major   gives   attachment   to   the 


798  LOWER  EXTREMITY. 

glTiteus  minimus:  it?  posterior  border  is  thick  and  rounded  and 
limits  the  digital  fossa  behind. 

On  the  inner  side  of  the  shaft,  at  its  junction  with  the  neck, 
is  the  trochanter  minor;  it  is  smaller  than  the  trochanter  major, 
prominent,  and  pyramidal;  to  it  and  to  the  shaft  of  the  bone  imme- 
diately below  it  is  attached  the  ilio-psoas  muscle. 

Upon  the  front  of  the  bone,  commencing  above  and  externally 
at  the  great  trochanter  and  curving  obliquely  downward  and  inward 
and  passing  around  the  inner  side  of  the  shaft,  just  below  the  lesser 
tuberosity,  is  the  so-called  spiral  line.  This  line,  on  the  back  of  the 
bone,  runs  into  the  linea  aspera,  forming  one  of  the  arms  of  this 
prominent  ridge.  This  spiral  line  is  well  marked,  and  upon  the  front 
of  the  bone  gives  attachment  to  the  capsular  ligament. 

Upon  the  posterior  aspect  of  the  bone,  a  prominent,  rounded 
line  is  presented,  which  runs  from  the  posterior  border  of  the  great 
trochanter  downward  and  inward  to  the  lesser  trochanter;  this  is 
known  as  the  posterior  intertrochanteric  line. 

The  acetabulum  is  a  large  cup-shaped  depression  corresponding 
to  the  junction  of  the  three  portions  (pubes,  ilium,  ischium)  of  which 
the  OS  innominatum  is  formed.  This  cavity  extends  downward  and 
inward  as  far  as  the  edge  of  the  obturator  foramen,  and  its  floor 
looks  downward,  outward,  and  forward;  it  is  surrounded  by  a  sharp, 
prominent  ridge  whose  summit  gives  attachment  to  the  ring-like 
cot^ioid  fibro-cartilage  which  serves  to  deepen  the  cavity,  constrict- 
ing its  orifice  and  gripping  the  head  of  the  femur,  thus  assisting  in 
retaining  it  within  the  socket  of  the  joint.  In  order  to  dislocate  the 
head  of  the  bone,  in  resecting  the  hip-joint,  it  is  necessary  to  nick 
this  cotyloid  ligament. 

The  lower  portion  of  the  margin  or  rim  of  the  acetabulum,  that 
part  wMch.  is  adjacent  to  the  obturator  foramen,  is  interrupted  by 
a  wide,  deep  notch,  the  cot^ioid  notch.  In  the  recent  state  this 
notch  is  bridged  over  by  a  ligamentous  band,  the  transverse  liga- 
ment ;  that  part  of  the  ring-like  cot^doid  fibro-cartilage  which  corre- 
sponds to  the  notch  is  applied  to  the  upper  surface  of  the  transverse 
ligament.  The  transverse  ligament  converts  the  cotyloid  notch  into 
a  foramen,  through  which  vessels,  nerves,  etc.,  pass  into  the  hip- 
joint. 

The  floor  of  the  acetabulum  is  partly  articular  and  partly  non- 
articular;  the  articular  part  is  the  smooth,  horseshoe-shaped  surface 
which  occupies  the  periphery  of  the  cavity;  the  non-articular  portion 


AMPUTATIONS,  RESECTIONS,  ETC.  799 

is  the  rough,  depressed  area  which  occupies  the  middle  of  the  cavity 
and  is  prolonged  down  along  the  floor  to  the  site  of  cotyloid  notch; 
this  non-articular,  depressed  surface  lodges  a  mass  of  fat  and  its 
margins  give  attachment  to  the  ligamentum  teres. 

The  hip-joint  is  provided  Avith  a  capsular  ligament/  which  is 
attached  above  around  the  margin  of  the  acetabulum  and  transverse 
ligament  (which  completes  the  circumference  of  the  acetabulum  be- 
low) ;  below  it  is  attached  to  the  femur;  in  front,  to  the  spiral  line 
as  far  as  the  lesser  trochanter;  behind  it  is  attached  to  the  surface 
of  the  neck  proper,  one-half  to  two-thirds  inch  above,  away  from, 
the  posterior  intertrochanteric  line.  The  capsule  is  materially 
strengthened  by  the  circular  fibers  that  are  woven  into  it  (ligament 
of  Webber). 

The  capsule  is  reinforced  by  three  auxiliary  bands  of  fibers. 
The  most  important  is  the  ilio-femoral  band,  which  is  thickest^ 
widest,  and  longest;  it  is  attached  above  to  the  ilium  just  below  and 
behind  the  anterior  inferior  spinous  process  and  below  spreads  out 
and  is  attached  along  the  spiral  line,  from  the  greater  to  the  lesser 
trochanter ;  it  is  known  as  the  "Y^'  ligament  of  Bigelow. 

The  ischio-femoral  band,  is  attached  to  the  ischium  behind  and 
below  the  acetabulum  (to  the  upper  part  of  the  groove  for  the  tendon 
of  the  ol)turator  extemus),  and  to  the  femur  it  is  attached  at  the 
upper  part  of  the  trochanter  major  and  spreads  out  and  encircles 
the  capsule. 

The  pectineo-  or  pubo-  femoral  band  is  thin,  and  attached  to 
the  pectineal  eminence  on  the  o?  innominatum  and  to  the  neck  of 
the  femur  behind  the  ilio-femoral  band,  being  incorporated  with  the 
lowermost  fibers  of  the  ilio-femoral  band. 

The  transverse  ligament  is  a  fibrous  band  that  bridges  across  the 
notch  in  the  lower  part  of  the  rim  of  the  acetabulum,  thus  convert- 
ing the  cotyloid  notch  into  a  foramen. 

The  cotyloid  ligament  is  a  complete  fibro-cartilaginoiis  ring 
which  is  attached  to  the  edge  of  the  bony  rim  and  the  transverse 
ligament,  encircling  the  acetabulum  and  deepening  the  cavity  and 
constricting  its  orifice. 

The  ligamentum  teres  is  an  interarticular  fibrous  band  which 
passes  between  the  head  of  the  femur  and  the  bottom  of  the  acetab- 
ulum. It  is  attached  in  the  bottom  of  the  acetabulum  to  the  mar- 
gins of  the  rough  space  and  to  the  transverse  ligament ;  its  narrow 
*end  is  attached  to  a  dimple  which  marks  the  apex  of  the  posterior 


§00  LOWER  EXTREMITY. 

inferior  quadrant  of  the  head  of  the  femur.  It  is  usually  a  strong 
band. 

The  rough  depression  in  the  bottom  of  the  acetabular  cavity  is 
filled  in  with  a  cushion  of  fat  in  which  the  vessels  that  pass  along 
the  ligamentum  teres  to  supply  the  head  of  the  bone  are  lodged. 

The  syuovial  membrane  of  the  hip- joint  lines  the  inner  surface 
of  the  capsule,  covers  the  mass  of  fat  in  the  floor  of  the  acetabular 
cavity,  and  is  thence  reflected  upon  the  ligamentum  teres  as  far  as 
the  head  of  the  femur  as  a  tubular  prolongation,  and  thus  practically 
shuts  the  teres  ligament  out  of  the  cavity  of  the  joint, 

A  large  bursa  lies  beneath  the  ilio-psoas  muscle  upon  the  front 
of  the  capsule;  this  often  communicates  with  the  joint.  Smaller 
bursas  are  located  between  the  various  tendons  and  adjoining  bony 
parts,  etc. 

The  hip-joint  is  covered  in  front  by  the  ilio-psoas  and  the  pectin- 
eus  muscles;  on  the  outer  side  by  the  glutei;  behind  by  the  gluteus 
maximus,  pyriformis,  obturator  internus  and  gemelli,  and  quadratus 
femoris ;  internally  and  below  by  the  obturator  externus. 

EXAETICULATION  OP  THE  ThIGH  AT  THE  HiP- JOINT   (WtETH). 

The  patient  lies  upon  the  back  with  the  thigh  extended  over  the  end  of 
the  table.  In  order  to  prevent  slipping  of  the  tourniquet,  which  is 
placed  about  the  thigh  for  the  purpose  of  compressing  the  femoral 
vessels  and  thus  controlling  the  hemorrhage,  two  long  pins  are  in- 
troduced through  the  soft  parts,  the  ligature  being  applied  above 
these.  The  pins  are  about  ten  inches  long  and  are  introduced  as 
follows : — 

One,  transfixing  the  soft  parts  on  the  outer  side  of  the  thigh, 
is  introduced  one  inch  below  the  anterior  superior  spine  of  the  ilium, 
and,  passing  backward  through  the  soft  parts  for  a  distance  of  about 
three  inches,  emerges  about  one  inch  below  the  crest  of  the  ilium; 
this  pin  transfixes  the  upper  part  of  the  tensor  vagina  femoris 
muscle. 

A  second  pin  is  introduced  through  the  soft  parts  on  the  inner 
side  of  the  thigh,  one  inch  below  the  pubic  bone;  it  passes  through 
the  adductor  muscles,  and  emerges  posteriorly  one  inch  below  the 
tuberosity  of  the  ischium;  in  introducing  this  inner  pin  one  must 
avoid  injuring  the  femoral  vein.  The  femoral  artery  passes  into  the 
thigh  underneath  Poupart's  ligament  at  a  point  which  corresponds 
to  the  middle  of  a  line  drawn  from  the  anterior  superior  iliac  spine  to 
the  pubic  spine.     The  femoral  vein  lies  just  to  the  inner  side  of  the 


AMPUTATIONS,  RESECTIONS,  ETC.  801 

artery.     Corks  are  applied  to  the  sharp  points  of  the  pins  after  they 
have  heen  introduced,  to  prevent  one  from  prickng  one's  self. 

The  tourniquet  is  placed  ai'ound  the  thigh  above  the  pins,  which 
prevent  its  slipping  down.     A  pad  may  be  placed  beneath  the  tourni- 


Fig.  352. — Exarticulation  at  Hip-joint.  Wyeth  pins  in  place  to  prevent  liga- 
ture from  slipping.  Upon  the  outer  side  of  thigh  the  incision  reaches  to  the 
bone.  A  circular  skin  flap  has  been  turned  back  and  the  muscles  and  blood- 
vessels divided  down  to  the  bone.     Clamps  applied  to  femoral  artery  and  vein. 

quet,  upon  the  front  of  the  thigh,  corresponding  to  tlie  location  of 
the  femoral  vessels,  to  still  further  secure  their  compression. 

The  operator  stands  on  the  outer  side  of  the  limb,  which  is 
supported  l)y  an  assistant.  With  a  long  knife  a  circular  incision  is 
made  through  the  skin  and  fat  down  to  the  deep  fascia;  this  in- 

51 


803  LOWER  EXTREMITY. 

cision  should  encircle  tlie  thigh  a  hand's  breadth  (five  inches)  below 
the  perineum. 

With  a  stout  scalpel  a  second  incision  is  made  along  the  outer 
side  of  the  thigh.  Commencing  above  the  great  trochanter,  this  in- 
cision is  carried  downward,  upon  the  surface  of  the  trochanter  and 
along  the  outer  side  of  the  thigh,  as  far  as  the  circular  incision, 
where  it  terminates.  This  second  incision  should  reach  to  the  bone 
throughout  its  entire  extent. 

The  edges  of  the  skin-flaj)  which  is  marked  out  by  the  circular  in- 
cision is  seized  and  dissected  away  from  the  deep  fascia  for  a  distance 
of  about  three  inches.  At  this  point,  the  skin-flap  being  retracted,  a 
circular  cut  is  made  with  the  long  knife,  through  the  muscles,  down 
to  the  bone,  dividing  the  vessels,  the  femoral  and  the  profunda  f emoris, 
which  lie  in  front  and  internal  to  the  bone.  These  vessels  are  now 
sought,  clamped,  and  tied.  In  order  to  get  better  access  to  the  vessels 
the  muscles  may  be  scraped  downward  away  from  the  shaft  of  the 
bone  for  a  short  distance.  We  should  make  sure  of  the  femoral  arter}^ 
and  vein  and  the  profunda  f emoris  and  its  vein ;  these  latter  lie  in  a ' 
deeper  plane  than  the  femoral  vessels.  Any  other  vessels  which  may 
be  visible,  searching  in  the  spaces  between  the  bundles  of  muscle,  are 
also  ligated. 

The  tourniquet  may  now  be  removed,  gradually  loosening  it  and 
catching  additional  vessels  as;  they  bleed,  and  then  the  pins  are  with- 
drawn or  the  tourniquet  and  pins  may  be  left  until  after  the  bone  has 
been  enucleated  and  the  amputation  is  complete,  but  in  all  cases  the 
main  vessels  should  always  be  secured  immediately  after  the  circular 
cut  through  the  muscles  has  been  made. 

The  next  step  in  the  operation  is  the  separation  of  the  soft  parts 
from  the  shaft  of  the  bone  and  the  dislocation  of  the  head  of  the  bone 
from  its  socket.  The  soft  parts  are  retracted  and  stripped  away  from 
the  bone,  working  with  the  edge  of  the  knife  close  to  the  bone  and 
rotating  the  limb  first  inward  and  then  outward  to  facilitate  this  part 
of  the  operation.  After  the  shaft  of  the  bone  has  been  denuded  of  its 
soft  parts  up  as  far  as  the  capsule  of  the  joint,  the  joint  is  opened  by 
incising  the  capsule  and  the  cotyloid  fibro-cartilage,  and  the  head  of 
the  bone  is  then  thrown  out  of  its  socket,  cutting  or  tearing  the  liga- 
mentum  teres,  and  any  remaining  soft  parts,  and  thus  completing  the 
exarticulation. 

After  ligating  any  bleeding  points  that  show  themselves  and 
having  cut  the  nerves  short,  the  edges  of  the  skin  are  united  with  in- 


AMPL'TATIOXS,  RESECTIONS,  ETC.  803 

terriijitecl  catgut  or  silkwonn-gut  sutures,  taking,  besides,  a  few  deep 
catgut  sutures  through  the  muscles.  A  hirge  drainage  tube  is  intro- 
duced; this  reaches  into  the  deepest  part  of  the  wound,  into  the 
acctabuhir  cavit}',  and  emerges  througli  the  lower  end  of  the  in- 
cision. 

EXARTICULATION'  AT  THE  HiP-JOIXT,  WITH  PrKLI.MIXAI! Y  LIGA- 
TION OF  THE  Common  Femoral.— Amputation  at  the  hip-joint  may  be 
accomplished  with  the  loss  of  very  little  blood  if,  as  a  preliminary  step, 
the  common  femoral  artery  and  vein  have  been  ligated  high  up  within 
two  inches  of  Poupart's  ligament;  i.e.,  above  the  origin  of  the  pro- 
funda femoris  branch.  After  the  common  femoral  artery  and  vein 
have  been  tied  a  circular  incision  is  made  around  the  thigh,  five  inches 
below  the  perineum,  and  in  addition  to  this  a  longitudinal  incision, 
which  commences  above  the  trochantar  major  and  is  carried  down 
the  outer  side  of  the  thigh  just  the  same  as  in  the  preceding  opera- 
tion. The  integument  is  then  reflected,  in  the  shape  of  a  tegumentary 
cuff,  for  a  distance 'of  about  three  inches,  at  which  level  the  muscles 
are  divided  layer  by  layer,  ligating  any  vessels  that  bleed  as  they  are 
met  with.  In  cutting  through  the  muscles  on  the  back  of  the  thigh 
we  meet  several  large  branches,  but  these  are  readily  secured  with 
clamps  as  they  spurt  and  are  then  ligated.  Having  cut  through  the 
muscles  down  to  the  bone,  the  soft  parts  are  separated  from  this  in  the 
usual  manner,  and  the  head  of  the  bone  turned  out  of  the  acetabulum 
and  the  amputation  thus  completed.  We  may  use  this  method  where 
tumor,  etc.,  prevent  the  use  of  the  Wyeth  pins. 

Resections.  Ankle-joint  (Langenbeck-Hueter). — This  opera- 
tion is  done  subperiosteally,  and  is  especially  applicable  to  cases  of 
traumatism.  The  foot  rests  with  its  inner  side  upon  a  thin  sandbag, 
the  knee  being  slightly  flexed. 

An  incision  about  three  inches  long  is  made  along  the  posterior 
border  of  the  iibula  just  in  front  of  the  sheath  of  the  peronei  tendons; 
this  is  carried  downward  as  far  as  the  tip  of  the  malleolus,  where  it  is 
turned  upAvard  for  a  short  distance  along  the  front  border  of  this  mal- 
leolus. This  incision  reaches  through  the  soft  parts  and  periosteum 
to  the  bone.  The  tissues  which  cover  the  bone  are  raised  subperioste- 
ally Avith  an  elevator,  laying  bare  all  of  the  lower  end  of  the  fibula  and 
taking  care  not  to  injure  the  peronei  tendons,  which  are  lodged  in  the 
groove  upon  the  posterior  border  of  the  external  malleolus.  There  is 
consideralde  difficulty  in  separating  the  periosteum  from  the  surface 
of  the  malleolus  below,  and  in  order  to  accomplish  this  it  may  be  neces- 


804 


LOWER  EXTREMITY. 


savj  to  resort  to  the  knife,  cutting  with  its  edge  close  upon  the  sur- 
face of  the  bone  or  else  one  may  chisel  away  a  thin  shell  of  the  cortex 
of  the  bone. 


Fig.  353. — Right  Foot,  Outer  Side.     External  incision  for  resection 
of  ankle  (Langenbeck-H ueter) . 


Fig.  354. — Right  Foot,  Inner  Side.     Anchor-shaped  incision  upon  inner 
side  of  ankle   for  resection   (Langenbeclc-Hueter) . 


In  isolating  the  lower  end  of  the  fibula  on  its  inner  aspect,  corre- 
sj)onding  to  the  attachment  of  the  interosseous  ligament  which  binds 


A-MPITATIONS,  RESECTIONS,  ETC.  805 

the  lower  ends  of  the  tibia  and  fibula  together,  care  should  be  taken 
to  stick  close  to  the  surface  of  the  bone,  so  as  to  leave  the  periosteum 
connected  with  the  interosseous  ligament. 

Xow.  corresponding  to  the  upper  part  of  the  wound,  the  fil)ula  is 
encircled  with  a  chain  or  wire  saw  and  divided,  or  it  may  be  cut 
through  Avith  a  chisel.  The  upper  end  of  the  detached  fragment  is 
then  seized  with  the  bone-forceps  and  wrenched  free  from  the  remain- 
ing ligaments  (external  lateral)  which  still  hold  it.  This  gives  access 
to  the  interior  of  the  joint,  and  through  this  opening  the  upper  artic- 
ular surface  of  the  astragalus  may  be  removed  with  the  chisel  or  sharp 
spoon  and  the  joint  irrigated  and  drained. 

One  may  stop  with  this  partial  operation,  or-  else  proceed  to 
do  a  complete  resection.  In  this  latter  case  the  foot  is  turned  so 
that  it  rests  upon  its  outer  side,  and  an  anchor-shaped  incision-  then 
made  which  consists  of  a  cut  two  and  one-half  or  three  inches  long, 
down  the  middle  of  the  inner  subcutaneous  surface  of  the  tibia  as 
far  as  the  tip  of  the  malleolus,  and  from  this  point  additional  incisions, 
which  are  carried  upward  along  the  anterior  and  posterior  borders  of 
the  malleolus  for  a  distance  of  about  one  inch.  These  incisions  all 
reach  through  the  periosteum  to  the  bone.  In  many  cases  the  single 
longitudinal  incision  will  suffice.  Through  this  incision  the  peri- 
osteum and  soft  parts  are  separated  from  the  loAver  end  of  the  tibia 
in  one  mass,  working  first  upon  the  anterior  surface  and  then  upon 
the  posterior  surface  of  the  bone,  and  avoiding  injury  to  the  tendons; 
upon  the  outer  surface  of  the  lower  end  of  the  tibia,  corresponding 
to  the  attachment  of  the  tibio-fibular  interosseous  ligament,  one 
should  work  as  close  as  possible  to  the  surface  of  the  bone. 

During  this  part  of  the  operation  the  edges  of  the  wound  are 
held  well  apart  with  blunt  retractors.  The  soft  parts  should  be 
separated  from  the  lower  end  of  the  bone  as  much  as  possible  with 
the  sharp-edged  periosteum  elevator,  but,  if  necessary,  one  may 
resort  to  the  use  of  the  knife,  keeping  close  to  the  surface  of  the 
bone,  or  may  chisel  away  a  thin  layer  of  the  cortex  of  the  bone. 
Finally,  the  internal  lateral  (deltoid)  ligaments  are  cut  close  to  the 
edge  of  the  malleolus, — it  is  better  to  separate  these  also  with  the 
elevator  or  the  chisel,— and  the  ankle-joint  is  now  open  upon  its 
inner  side.  The  lower  end  of  the  tibia  may  be  cut  through  with 
the  chain  or  wire  saw  or  chisel  upon  the  same  level  as  the  fibula  was 
divided ;  it  is  then  seized  with  a  bone-forceps  and  detached  from  any 
remaininor  bands  that  hold  it. 


806  LOWER  EXTREMITY. 

The  upper  articular  surface  of  the  astragalus,  if  desirable,  may 
now  be  sawn  olf  from  behind  forward  with  a  thin,  flat  saw,  taking 
care  of  the  tendons  on  the  back  and  front  of  the  joint,  or,  better, 
it  may  be  cut  away  with  the  chisel.  This  section  should  be  made 
through  such  a  plane  that,  when  the  sawn  surface  of  the  astragalus 
is  apposed  to  the  sawn  surface  of  the  tibia,  the  foot  will  be  at  right 
angles  to  the  leg.  There  is  a  tendency  to  make  the  section  through 
the  astragalus  upon  a  plane  which  would  place  the  foot  in  a  position 
of  extension  (plantar  flexion),  and  this  is  to  be  avoided. 

When  this  operation  is  performed  for  traumatism,  the  result  is 
good.  Much  of  the  bone  is  reproduced  and  the  parts  regain  almost 
their  former  contour;  any  excess  of  bone  that  is  produced  from  the 
detached  periosteum  is  usually  absorbed.  Portions  of  the  tibia,  even 
as  much  as  8  to  10  cm.,  have  been  removed  and  reproduced.  An 
ankylosed  ankle  is  the  preferable  result  after  this  operation;  the 
joints  between  the  bones  of  the  tarsus  eventually  give  considerable 
spring  to  the  foot.  When  the  •  operation  is  performed  for  tuber- 
culosis, frequently  no  bone  is  reproduced,  healing  fails,  and  we  have^ 
as  a  result,  a  wabbly  joint,  with  sinuses. 

It  may  not  be  necessary  in  all  cases  to  do  a  complete  resection, 
since  all  of  the  parts — for  example,  the  articular  surface  of  the 
astragalus — ^may  not  be  diseased,  etc.  Care  should  be  exercised  in 
applying  the  dressings  to  place  the  foot  at  a  right  angle  with  the  leg 
and  turned  somewhat  outward.  It  is  probably  wise  in  all  cases  to 
drain,  at  least  for  a  few  days.  The  edges  of  the  wound  are  approxi- 
mated with  interrupted  catgnt  sutures. 

With  Extirpation  of  the  Entire  Astragalus. — The  long  middle  in- 
cision on  the  inner  side  of  the  ankle  is  prolonged  downward  about  one 
inch  farther  than  described  in  the  foregoing  operation,  so  as  to  reach  to 
the  sustentaculum  tali,  and  at  its  lower  end  an  antero-posterior  incision 
is  added  Avhich  is  about  two  inches  long  and  which  penetrates  to  the 
bone  (see  Fig.  358).  The  soft  parts  are  separated  forcibly  with  the 
elevator  and  the  whole  of  the  astragalus  thus  brought  into  view. 
The  joint  between  the  head  of  the  astragalus  and  the  scaphoid  is 
opened  (tuberosity  of  the  scaphoid  is  the  guide),  and  also  the  joint 
between  the  astragalus  and  the  os  calcis  (sustentaculum  tali)  ;  after 
this  the  astragalus  is  seized  with  a  bone-forceps,  and,  twisting  and 
at  the  same  time  cutting  close  to  the  bone,  it  is  removed.  In  re- 
secting the  ankle-joint  for  tuberculosis,  if  the  astragalus  is  diseased, 
it  is  well  to  remove  this  bone  entire. 


AMPUTATIONS,  RESECTIONS,  ETC. 


80' 


AxKLE-JOiXT  (Koexig). — Tliis  is  a  satisfactory  operation,  espe- 
cially for  tuberculous  joints.  The  lower  part  of  the  leg  rests  upon  a 
sandbag,  the  foot  being  elevated  and  turned  outward.  An  incision  is 
made  upon  the  inner  side  of  the  ankle,  commencing  an  inch  or  an  inch 
and  one-half  above  the  level  of  the  joint,  and  passing  down  along  the 
anterior  border  of  the  tibia  and  inner  malleolus  parallel  with  and  just 
internal  to  the  extensor  tendons  which  lie  upon  the  front  of  the  joint. 


MP. 


Pig.  355.— ff,  incisions  for  resection  of  ankle  (Eoenig);  M.P.,  articula- 
tion between  metacarpal  bone  of  the  big  toe  and  first  phalanx;  8,  location  of 
tubercle  of  scaphoid.  Incision  for  amputation  of  big  toe  with  removal  of  the 
first  metatarsal. 

This  incision  penetrates  through  the  integument  and  periosteum  to 
the  tibia,  and  is  continued  downward  across  the  ankle-joint,  into  which 
it  opens,  and  then  curves  forward  upon  the  neck  of  the  astragalus  as 
far  as  the  tubercle  of  the  scaphoid. 

A  similar  incision  is  made  upon  the  outer  side  of  the  joint, 
commencing  above  at  the  same  level  as  the  internal  incision  and 
passing  downward  along  the  anterior  edge  of  the  outer  malleolus, 
across  the  ankle-joint,   into  wliich  it  opens,   and  ending  at  a  point 


808  LOWER  EXTREMITY. 

ojoposite  the  lower  end  of  the  inner  incision.  This  incision  runs 
parallel  with  the  outer  margin  of  the  extensor  group  of  tendons. 

Between  these  two  incisions  there  is  a  hridge  of  tissues  consist- 
ing of  integument,  anterior  tibial  vessels  and  nerve,  extensor  ten- 
dons, anterior  ligament,  and  synovial  membrane.  This  mass  of  soft 
parts  is  freely  separated  from  the  front  of  the  tibia  above  and  from 
the  astragalus  below,  as  much  as  j)ossible  subperiosteally  with  the 
elevator,  and  when  necessary  with  occasional  snips  with  the  scissors 
or  knife. 

Access  to  the  ankle-joint  is  now  fairly  free,  and  one  may  com- 
mence the  excision  of  the  diseased  synovial  membrane  with  mouse- 
toothed  forceps  and  scissors;  the  ends  of  the  tibia  and  fibula  and 
the  articular  surface  of  the  astragalus  may  also  be  reached  with  the 
sharp  spoon. 

If  it  is  desirable  to  resect  the  ends  of  the  bones  and  it  becomes 
necessary  to  gain  still  better  access  to  the  interior  of  the  joint,  a 
thin  shell  of  the  cortex,  carrying  the  periosteum  and  the  attach- 
ments of  the  ligaments,  may  be  chiseled  away  from  the  surface  of  the 
inner  and  also  from  the  surface  of  the  outer  malleolus,  leaving  them 
bare  and  free.  Drawing  the  soft  parts  widely  asunder  with  blunt 
hooks,  a  broad  chisel  may  be  applied,  through  the  inner  incision,  to 
the  lower  end  of  the  tibia,  and  this  may  then  be  divided;  the  frag- 
ment which  is  thus  detached  is  seized  with  bone-forceps  and  re- 
moved, cutting  the  remaining  attachments  close  to  the  bone  and 
taking  care  not  to  injure  the  tendons  which  lie  close  to  the  back  of 
the  bone  nor  the  posterior  tibial  vessels  and  nerve.  The  lower,  bare 
end  of  the  fibula  may  be  treated  in  a  similar  manner,  avoiding  the 
peroneal  tendons  in  the  groove  upon  its  posterior  surface.  In  laying 
bare  the  malleoli  one  should  tiy  to  separate  the  lateral  ligaments 
with  the  chisel  subperiosteally  in  preference  to  cutting  them. 

The  articular  surface  of  the  astragalus  may  be  removed  with  the 
broad  chisel  or  with  a  narrow,  thin-bladed  saw,  the  section  being 
made  through  a  plane  which  will  allow  the  foot  to  be  placed  at  a 
right  angle  with  the  leg. 

In  most  cases  of  tuberculous  joints,  when  the  astragalus  is  in- 
volved, it  is  probably  better  to  remove  this  bone  entire;  this  will 
also  permit  treatment  of  the  joints  between  Hhe  astragalus  and 
OS  calcis  and  the  astragalus  and  scaphoid  if  these  are  involved,  and  this 
is  frequently  the  case.  The  astragalus  is  readily  removed  through  the 
inner  incision,  .first  opening  the  joint  between  the  head  of  the  astrag- 


A.Ml'LTATIOXS,  RESECTIONS,  ETC.  809 

alus  and  the  scaphoid,  and  tlien  the  joint  between  the  head  of  the 
astragalus  and  tlie  susteritaculum  tali  of  the  os  ealcis.  The  astragalus 
is  seized  with  a  lion-tooth  forceps,  and,  cutting  its  attachments  close 
to  the  bone,  it  is  twisted  free. 

Whether  the  entire  astragalus  is  removed  or  not  in  cases  of 
tuberculosis  the  whole  synovial  membrane  lining  of  the  ankle-joint 
should  be  removed  with  toothed  forceps  and  scissors;  that  part  of 
the  membrane  which  lines  the  posterior  portion  of  the  capsule  is 
dilFicult  to  reach,  but  its  removal  may  be  facilitated  by  drawing  the 
foot  strongly  downward  away  from  the  til)ia  and  at  the  same  time 
strongly  reflecting  the  anterior  flap  or  bridge  of  soft  parts. 

Usually  there  are  no  vessels  to  tie.  Drainage  tubes  may  be  in- 
troduced on  each  side  and  the  wound  packed  with  iodoform  gauze. 
The  edges  of  the  wounds  are  brought  together  with  interrupted  catgut 
sutures,  being  left  partly  open  to  allow  for  the  drainage  tubes  and 
gauze.    The  foot  is  dressed  at  a  right  angle  to  the  leg. 

AxKLE-joiXT  (Lauensteix). — A  ver}'  satisfactory  method,  espe- 
cially for  tuberculous  joints.  The  knee  is  slightly  flexed,  and  the 
foot  rests  with  its  inner  surface  upon  a  thin  sandbag.  The  in- 
cision is  placed  upon  the  outer  side  of  the  joint,  passing  through  the 
skin  and  subcutaneous  fat  and  exposing  the  external  surface  of  the 
outer  malleolus  and  the  lower  end  of  the  fibula  for  a  distance  of  about 
three  inches.  The  surface  of  the  fibula  thus  exposed  is  subcutaneous, 
and  is  included  between  the  tendon  of  the  peroneus  tertius  in  front 
and  the  tendon  of  the  peroneus  brevis  behind;  from  the  tip  of  the 
outer  malleolus  the  incision  curves  foru^ard  and  inward  across  the  dor- 
sum of  the  foot,  terminating  just  external  to  the  tendon  of  the  pero- 
neus tertius,  which  should  not  be  cut. 

The  joint  is  now  opened  in  front  of  the  external  malleolus  by 
cutting  the  anterior  fasciculus  of  the  external  lateral  ligament,  and 
then  the  integument,  together  with  the  extensor  tendons  and  other 
soft  parts,  including  the  anterior  portion  of  the  capsular  ligament, 
are  separated  from  the  front  of  the  tibia  wnth  the  periosteum  elevator, 
these  soft  parts  being  meanwhile  drawn  forcibly  forward,  away  from 
the  front  surface  of  the  tibia,  with  a  blunt  hook. 

The  posterior  margin  of  the  incision  is  next  seized  and  retracted 
and  the  sheath  of  the  peroneal  tendons  opened;  these  tendons,  to- 
gether with  the  integument,  are  drawn  well  back  out  of  the  way  with 
a  blunt  hook  and  the  remaining  fasciculi  of  the  external  lateral  liga- 
ment (middle  and  posterior)  then  divided. 


810 


LOWER  EXTREMITY. 


The  foot,  being  somewhat  extended  in  order  to  relieve  the  ten- 
sion of  the  peronei  tendons,  may  now,  with  moderate  force,  be  com- 
pletely dislocated  by  rotating  it  inward  upon  its  long  axis  in  a  hinge- 
like fashion  around  the  internal  malleolus. 

All  parts  of  the  joint  are  now  accessible ;  the  synovial  membrane 
may  be  dissected  away  with  a  thumb  forceps  and  scissors,  and  the 
upper  articular  surface  of  the  astragalus,  if  desired,  may  be  chiseled 
away  or  resected  with  a  thin,  fiat  saw,  or,  by  extending  the  incision 
somewhat,  the  entire  bone  may  be  removed.  If  the  tibia  and  fibula 
are  diseased,  the  soft  parts  about  the  lower  ends  of  these  bones  may 


Fig.  356. — Resection   of  Anlile-joint.     Lauenstein's   incision. 


be  detached,  preferably  subperiosteall}^,  with  the  elevator,  and  the  dis- 
eased portion  of  the  bones  then  resected  with  the  saw.  If  the  articular 
surface  only  of  the  astragalus,  and  not  the  whole  bone,  is  to  be  re- 
moved, one  should  take  care  to  make  the  section  through  the  bone  in 
such  a  plane  that,  when  the  foot  is  replaced,  the  cut  surfaces  of  the 
astragalus  and  tibia  will  permit  of  the  foot  being  placed  at  a  right 
angle  with  the  leg.  There  is  a  marked  tendency,  in  resecting  the 
articular  surface  of  the  astragalus,  to  carry  the  section  through  a  plane 
which  would  result  in  the  foot's  being  joined  to  the  leg  at  an  obtuse 
angle,  in  a  position  of  extension,  and  this  is  to  be  avoided. 

Ankle-joint,  Osteoplastic  ( Mikulicz- Wladimirow). — The 
patient  lies  upon  the  abdomen.  A  ti'ansverse  incision  is  made 
across  the  sole  of  the  foot.  This  incision  commences  on  the  outer 
border   of  the  foot  a  finger's  breadth  behind  the  tuberositv  which 


AMPUTATIONS,  RESECTIONS,  ETC. 


811 


marks  the  base  of  the  fifth  metatarsal  bone  (little  toe),  and  ends 
on  the  inner  side  of  tlie  foot  at  tbe  tubercle  of  the  scaphoid.  From 
either  end  of  this  incision,  upon  either  side  of  the  foot,  an  additional 
incision  is  carried  obli(|ucly  upward  and  backward  across  the  lower  end 
of  each  malleolus  to  tlieir  posterior  borders,  and  then  still  another 
incision  is  made  transversely,  just  above  the  heel,  uniting  the  ends  of 
the  two  lateral  incisions  and  dividing  the  tendo  Achillis  and  the  poste- 
rior tibial  vessels.  All  these  incisions  penetrate  to  tbe  bone.  The  foot 
is  now  forcibly  flexed  (dorsal  flexion)   and  the  ankle-joint  is  opened 


Fig.  357. — Right  Foot,  Inner  Side.  Line  of  incision  for  Mikulicz-Wladimi- 
row  osteoplastic  resection  of  the  ankle-joint.  Dotted  lines  indicate  section 
through  the  bones. 


from  behind  and  the  lateral  ligaments  are  cut.  The  astragalus  and 
the  OS  calcis  are  then  dissected  out  of  the  mass  of  soft  parts  in  which 
they  are  located,  working  with  the  edge  of  the  knife  close  to  the  sur- 
face of  the  bones;  during  this  step  of  the  operation  the  bones  are 
forcibly  drawn,  first  to  one  side  and  then  to  the  otber,  in  order  to 
facilitate  their  enucleation,  and,  working  forward,  tbe  joint  between 
the  astragalus  and  the  os  calcis  behind  and  the  scaphoid  and  cuboid  in 
front  is  finally  opened.  The  remaining  ligaments  and  bands  are  then 
severed  and  the  bones  removed. 

The  soft  parts  around  the  lower  end  of  the  tibia  and  fibula  are 
now  separated,  cutting  with  the  edge  of  the  knife  close  to  the  surface 


812  LOWER  EXTREMITY. 

of  the  bones,  and  a  thin  slice  of  the  lower  end  of  the  tibia,  including 
both  malleoli,  is  sa\m  off. 

A  thin  slice,  including  the  articular  surfaces,  is  likewise  sawn 
off  from  the  scaphoid  and  cuboid,  so  that  when  the  foot  is  extended 
(plantar  flexion)  the  sawn  surfaces  of  the  cuboid  and  scaphoid  may 
be  apposed  to  the  sawn  surfaces  of  the  tibia  and  fibula,  the  long  axis 
of  the  leg  being  thus  prolonged  into  the  foot,  as  a  direct  line,  the 
patient  walking  upon  the  heads  of  the  metatarsal  bones  and  the 
phalanges. 

The  posterior  tibial  vessels  which  lie  behind  the  ankle-joint, 
t-o  the  inner  side  of  the  tendo  Achillis,  are  cut,  and  must  be  ligated. 
The  bones  ma}^  be  retained  in  contact  with  sutures  of  chromicized 
catgut  carried  through  drill  holes,  but  this  is,  as  a  rule,  unnecessary, 
especially  if  the  foot  is  put  up  in  plaster.  The  skin  wound  is  closed 
with  interrupted  catgut  sutures. 

One  should  be  careful  that  the  integument  on  the  front  of  the 
ankle,  which  is  redundant  after  excision  of  these  bones,  does  not 
interfere  through  its  bulk,  'foundling,"  with  the  correct  apposition 
of  the  bones.  One  may  overcome  this  tendency  by  passing  several 
quilting  sutures  through  this  mass  of  soft  parts. 

Knee-joint. — A  tourniquet  is  applied  about  the  upper  part  of 
the  thigh.  The  patient  lies  upon  the  back  with  the  leg  extended,  the 
operator  standing  upon  the  side  of  the  table  corresponding  to  the  joint 
which  is  to  be  resected. 

The  usual  incision  (Textor)  and  probably  the  best  for  most 
cases  is  convex  downward,  passing  across  the  front  of  the  joint, 
below  the  patella,  and  extending  from  the  middle  of  one  condyle  to 
a  similar  point  upon  the  other.  This  incision  should  reach  deep  to 
the  bone,  and  below  the  patella  divides  the  ligamentum  patellae. 

The  knee-joint  having  been  thus  opened,  the  limb  is  strongly 
flexed  at  the  hip  and  Iniee,  with  the  sole  of  the  foot  resting  upon  the 
table,  and  it  is  thus  supported  by  an  assistant.  The  lateral  ligaments 
and  the  lateral  portions  of  the  capsule  are  now  divided,  cutting  them 
close  to  the  surface  of  the  femur. 

The  knee  being  still  more  markedly  flexed,  the  crucial  ligaments 
are  divided  close  to  their  attachment  to  the  upper  surface  of  the  tibia, 
cutting  with  the  edge  of  the  knife  directed  downward,  as  if  one  would 
cut  into  the  articular  surface  of  the  upper  end  of  the  tibia;  if  the 
ligaments  are  divided  with  the  edge  of  the  Imife  directed  backward, 
one  may  accidentally  cut  the  popliteal  vessels. 


AMPUTATIONS,  EESECTIONS,  ETC. 


813 


The  anterior  flap,  wliicli  includes  the  patella,  should  be  dis- 
sected back  and  retracted  sufficiently  to  allow  free  access  into  the 
sMiovial  pouch,  which  is  located  above  the  patella,  between  the  quad- 
riceps tendon  and  the  front  of  the  femur. 


Fig.  358.— Right  Leg,  Inner  Side.  AS,  incision  upon  tlie  inner  aspect  of 
the  ankle  for  resection  of  the  astragalus;  K,  Textor  incision  for  resection  of 
the  knee-joint.     Dotted  lines  indicate  planes  of  section  through  the  bones. 


"With  mouse-tooth  forceps  and  blunt-pointed  scissors,  curved 
on  the  flat,  the  synovial  membrane  which  lines  the  joint  may  now  be 
entirely  resected.     If  the  bones   are  healthy,   one  may  stop  at  this 


814  LOWER  EXTREMITY. 

stage  of  the  operation  and  close  the  wound,  after  irrigating  thor- 
oughly and  231'oviding  for  suitable  drainage  (arthrectomy). 

In  resecting  that  jDart  of  the  synovial  membrane  which  lines 
the  posterior  part  of  the  capsule  one  should  avoid  cutting  deeply, 
on  account  of  the  liability  to  injure  the  popliteal  vessels,  which  lie 
adjacent  to  this  part  of  the  capsule.  There  is  rather  less  danger 
of  doing  this  if  the  posterior  ligament  is  put  upon  the  stretch  by 
drawing  the  tibia  away  from  the  femur  while  this  part  of  the  syn- 
ovial sac  is  being  excised.  This  portion  of  the  synovial  membrane 
is  also  more  accessible  after  the  ends  of  the  bones  have  been 
resected. 

If  the  disease  in  the  bones  is  limited  to  one  or  more  foci,  these 
may  be  thoroughly  scooped  out  with  a  sharp  spoon,  thus  avoiding 
the  resection  of  the  ends  of  the  bones.  Especially  in  children  one 
should  avoid,  wherever  possible,  the  resection  of  the  ends  of  the 
bones,  since  interference  with  the  epiphyseal  line  may  retard  very 
much  the  subsequent  growth  of  the  limb. 

The  patella  is  usually  extirpated  if  the  ends  of  the  femur  and 
tiljia  are  resected,  even  if  it  is  apparently  not  diseased.  It  is  grasped 
with  double  sharp  hooks  and  excised,  cutting  with  the  edge  of  the 
knife  close  to  the  surface  of  the  bone. 

If  one  decides  to  resect  the  ends  of  the  bones,  the  lower  end 
of  the  femur  is  first  removed,  separating  the  soft  parts  back  as  far 
as  necessar}^,  and  working  with  the  scalpel  close  to  the  bone.  The 
end  of  the  femur,  stripped  of  its  soft  parts,  is  forced  upward,  out 
of  the  wound,  above  the  level  of  the  tibia  (hip  flexed)  and  with 
a  sharp,  broad  saw  the  section  is  made  through  the  end  of  the  bone 
from  before  baclvo^ard,  commencing  by  placing  the  heel  of  the  saw 
upon  the  l^one  and  making  a  groove  by  drawing  the  instrument 
firmly  backward.  The  femur  should  be  steadied  with  both  hands  of 
an  assistant  who  supports  himself  by  resting  his  elbows  upon  the 
table.  The  end  of  the  bone  should  he  forced  sufficiently  far  upward 
out  of  the  wound  so  as  to  make  the  use  of  a  towel  to  protect  the  soft 
parts  during  its  section  unnecessary.  The  piece  of  bone  resected 
must  be  of  the  same  thickness  anteriorl}^,  posteriori}^,  and  upon  either 
side;  otherwise,  when  the  operation  is  completed,  the  limb  will  be 
found  to  be  in  a  position  of  knock-knee  or  bow-leg,  or  there  will  be 
too  much  or  too  little  extension. 

The  section  should  pass  through  a  plane  which  is  parallel  with 
the  articular  surface  of  the  bone,  and  not  at  right  angles  with  the  long 


AMPUTATIONS,  RESECTIONS,  ETC. 


815 


axis  of  the  bone,  and  therefore  in  making  the  section  one  should 
disre<yard  the  long  axis  of  the  bone,  and  rather  keep  his  eye  on  the 
plane  of  the  articular  surface. 

The  end  of  the  tibia  is  now  likewise  stripped  of  its  soft  parts  and 
projected  upward  out  of  the  wound  well  beyond  the  sawn  surface  of 


C- 


Fig.  359. — Resection  of  Knee-joint.  A,  A?-,  long  axes  of  ttie  femur  and 
tibia;  B,  line  drawn  at  right  angles  to  the  long  axis  of  the  femur.  C,  lines 
through  the  lower  end  of  the  femur  and  upper  end  of  the  tibia  parallel  with 
the  plane  of  the  articular  surfaces.  Through  these  planes  the  section  should 
be  made  in  resecting  the  knee-joint. 

the  femur,  and  a  section  of  the  bone  removed,  as  in  the  case  of  the 
femur,  parallel  with  the  plane  of  its  articular  surface. 

At  times  it  is  necessary  to  excise  two  or  three  inches  of  the  bones 
(femur  and  tibia  together),  but  one  should  remove  as  little  as  the 
conditions  present  will  permit,  especially  in  children.  The  sharp 
spoon  may  be  used  to  extirpate  foci  which  extend  into  the  substance 


816  LOWER  EXTREMITY. 

of  the  bone  be3^ond.  the  surface  exposed  by  the  section,  and,  if  the 
cortex  is  healthy,  one  may  remove  ninch  of  the  medullary  portion  of 
a  bone  rather  than  sacrifice  more  of  the  length  of  the  limb  by  removing 
a  thicker  segment  of  bone. 

The  limb  should  now  be  extended  and  the  position  of  the  joint 
noted;  when  the  ends  of  the  bones  are  brought  together  there  should 
be  the  normal  slight  bowing  inward  and  a  slight  degree  of  flexion 
(five  degrees). , 

If  the  position  of  the  limb  is  not  satisfactory,  one  may  remove  a 
further  section  from  one  of  the  bones  to  correct  it;  but  the  necessity 
for  this  second  section  should  be  avoided. 

The  ]30sition  of  the  bones  being  satisfactory,  all  loose,  ragged 
tissue  is  cut  away  and  any  remaining  portion  of  the  synovial  mem- 
brane that  has  been  overlooked  excised. 

In  most  cases  it  is  well  to  insert  tubes  for  drainage,  one  on  each 
side.  These  should  reach  well  up  into  the  recess  beneath  the  quadri- 
ceps muscles,  between  it  and  the  front  of  the  femur;  in  addition, 
strips  of  iodoform  gauze  may  be  packed  into  the  wound,  the  ends 
emerging  through  the  incision  on  each  side;  if  tubes  are  used,  they 
should  be  fixed  to  the  edge  of  the  skin  with  a  silkworm-gut  stitch 
to  prevent  their  slipping  out.  The  front  part  of  the  skin  incision 
is  closed  with  interrupted  silkworm-gut  stitches. 

If  the  limb  is  placed  in  a  good,  firm,  plaster-of- Paris  splint,  the 
ends/  of  the  bones,  as  a  rule,  remain  in  good  position.  A  sharp  edge 
of  either  bone  should  not  be  left  projecting  into  the  popliteal  space 
(popliteal  vessels).  If  it  is  desired  to  fix  the  ends  of  the  bones  they 
may  be  joined  together  with  two  stout  chromicized  catgut  sutures 
which  pass  through  drill  holes  placed  near  the  anterior  margin  of  the 
sawn  surfaces  of  the  bones,  one  on  each  side  of  the  middle  line,  or, 
after  the  skin  has  been  sutured,  the  bones  may  be  joined  by  two  nails, 
one  driven  through  the  front  of  the  upper  end  of  the  tibia  and 
reaching  obliquely  upward  into  the  sawn  surface  of  the  femur,  and 
the  other  passing  through  the  front  surface  of  the  femur  and  reaching 
down  into  the  upper  end  of  the  tibia.  Small  incisions  may  be  made 
in  the  skin  to  allow  the  introduction  of  the  nails. 

These  accessory  measures,  for  the  purpose  of  holding  the  bones 
in  apposition,  are,  as  a  rule,  unnecessary  if  the  ends  of  the  bones  have 
been  sawn  square,  and  fit  well,  and  a  good  plaster  splint  is  applied. 
In  adjusting  the  plaster  splint  one  should  see  that  the  foot  is  slightly 
everted,  so  that  the  patient  will  not  "toe  in.^^ 


AMPUTATIONS,  RESECTIONS,  ETC.  817 

Before  suturing  the  wound  the  tourniquet  may  be  removed  and 
any  spurting  vessels  secured;  usually  there  are  few  or  none,  and  any 
slight  oozing  may  be  controlled  by  the  pressure  of  the  dressing. 

Instead  of  the  incision  described  above,  the  knee-joint  may  be 
opened  by  an  incision,  with  the  convexity  directed  upward,  passing 
across  the  limb  above  the  upper  border  of  the  patella.  This  is  the 
reverse  of  the  incision  described  above,  and  gives  very  free  access  to 
the  synovial  pouch  under  the  quadriceps  tendon. 

Yolknumn  makes  a  transverse  incision  across  the  front  of  the 
knee,  through  the  skin  down  to  the  surface  of  the  patella,  the  knee 
being  slightly  flexed  and  resting  upon  a  sandbag;  corresponding  to 
this  incision  through  the  skin,  the  patella  is  sawn  through  trans- 
versely. To  this  may  be  added  two  lateral  incisions,  one  on  each  side 
of  the  joint  running  up  and  down.  We  then  have  an  H-shape  in- 
cision. This  incision  is  especially  adapted  to  those  cases  where  the 
disease  is  limited  to  the  sjaiovial  membrane  alone;  so  that  after  its 
excision  the  segments  of  the  patella  may  be  sutured  with  chromi- 
cized  catgut.    This  incision  is  often  desirable  in  children. 

Hip-joint  (Langenbeck). — This  operation  is  done  as  much 
as  possible  subperiosteally.  The  patient  lies  upon  the  well  side  of 
the  body,  with  the  hip  and  knee  slightly  flexed.  A  longitudinal  in- 
cision is  made  over  the  outer  side  of  the  hip  four  to  five  inches  long; 
it  commences  two  or  three  inches  above  the  upper  border  of  the  great 
trochanter,  upon  a  line  corresponding  to  the  long  axis  of  the  femur, 
and  from  this  point  is  continued  straight  down  upon  the  outer  surface 
of  the  trochanter  and  ends  upon  the  upper  part  of  the  shaft  of  the 
femur;  the  incision  throughout  its  whole  length  penetrates  to  the 
bone;  that  portion  of  the  incision  which  lies  above  the  trochanter 
passes  through  the  fibers  of  the  glutei  muscles  down  to  the  surface 
of  the  ilium,  Avhich  it  reaches  just  above  the  margin  of  the  acetabulum, 
exposing  the  capsule  of  the  joint. 

Sharp  retractors  are  inserted  deep  in  the  incision  and  the  soft 
parts  drawn  forcibly  asunder.  The  capsule  is  incised  from  the  rim 
of  the  acetabulum  downward  toward  the  great  trochanter,  the  coty- 
loid ligament,  also,  being  nicked,  or  may  be  separated  from  the  bony 
rim  of  the  acetabulum  for  a  short  distance  on  either  side  of  the 
incision  in  the  capsule. 

With  the  periosteum  elevator,  or,  when  necessary,  with  the  knife 
or  chisel,  the  tendons,  together  with  the  periosteum  and  the  capsule, 
are  separated  from  the  greater  trochanter  and  the  neck  of  the  femur ; 


818  •  LOWER  EXTREMITY. 

this  should  be  accomplished  as  much  as  possible  subperiosteally  with 
the  sharp-edged  periosteum  elevator;  but,  where  the  attachment  of 
the  parts  to  the  bones  is  ver}^  intimate,  it  may  be  necessar}^  to  resort 
to  the  knife,  cutting  with  its  edge  close  to  the  surface  of  the  bone,  or 
the  chisel  may  be  used,  chipping  off  a  thin  shell  of  the  cortex,  which 
carries  the  attached  tendons  with  it.  An  assistant  rotates  the  limb 
inward  or  outward  as  may  be  necessary  to  facilitate  this  part  of  the 
operation. 


Fig.  360. — Resection  of  Hip.     Langenbeck's  incision 


In  this  way  the  upper  end  of  the  femur  is  denuded.  Pains 
should  be  taken  to  separate  the  tendon  of  the  obturator  extemus, 
which  is  attached,  in  the  digital  fossa,  upon  the  inner  aspect  of  the 
great  trochanter,  and  also  the  tendons  that  are  attached  to  the  upper 
border  of  the  great  trochanter. 

In  order  to  cut  the  ligamentum  teres  the  thigh  is  flexed,  rotated 
inward,  and  adducted,  in  this  way  partly  luxating  the  head  of  the 
bone;    a  long,  narrow  knife  is  then  introduced  into  the  joint  above 


AMPUTATIONS,  RESECTIONS,  ETC. 


819 


and  behind,  and  sweeping  downward  and  forward  across  the  head 
of  the  bone,  the  ligament  is  usually  cut.  In  operating  on  diseased 
joints  it  is,  as  a  rule,  not  necessary  to  cut  the  ligamentum  teres,  as  it 
is,  in  most  cases,  already  destroyed,  or,  at  any  rate,  readily  ruptures 
upon  forcibly  manipulating  the  joint  (adduction  and  rotation  inward). 
The  head   of   the   femur   is   then   completely   luxated   backward  by 


Fig.  361. — Resection  of  the  Hip.  Anthony  White's  Incision.  Commences 
anteriorly  midway  between  the  anterior  superior  spine  of  the  ilium  and  the 
upper  border  of  the  trochanter  major  and  curves  backward  above  the  tro- 
chanter major  and  then  downward  behind  the  trochanter  for  a  distance  of 
about  two  Inches. 


manipulation  (flexion,  adduction,  and  rotation  imyard)  and  forced 
out  of  the  wound,  when  the  head  and  neck  may  be  readily  removed 
with  a  Gigli  or  chain  saw,  with  a  flat  saw,  or  with  a  chisel. 

Some  surgeons  make  it  a  practice  to  remove  the  trochanter  as 
well  as  the  head  and  neck  of  the  femur,  making  the  line  of  section 
through  the  shaft  of  the  bone  just  below  the  great  trochanter.     In 


820  LOWER  EXTREMITY. 

order  to  do  this  it  is  necessary  to  separate  the  periosteum,  etc.,  corre- 
spondingly lower  down  upon  the  shaft  of  the  femur.  If  the  trochanter 
is  healthy,  it  is  unnecessary  to  remove  it;  yet,  if  at  all  suspicious,  it 
is  hotter  to  make  the  section  through  the  bone  below  the  great  tro- 
chanter, removing  the  great  trochanter  as  well  as  the  head  and  neck, 
because  the  result  is  just  as  good,  and  many  surgeons  claim  better, 
than  when  it  is  left. 

Now,  rotating  inward  and  outward,  but  chiefly  by  extension  of 
the  limb,  pulling  strongly  upon  the  femur  and  holding  the  edges  of 
the  wound  widely  apart  to  give  us  room,  we  may  proceed  to  excise  the 
synovial  membrane,  using  long,  sharp  scissors,  curved  upon  the  flat, 
and  mouse-tooth  forceps. 

If  the  acetabulum  is  diseased,  it  may  be  curetted  with  a  sharp 
spoon  or  even  resected  with  the  chisel  and  mallet.  A  sinus  may  be 
found  leading  through  the  acetabulum  to  a  focus  within  the  pelvis, 
in  which  case  drainage  of  the  joint  may  be  combined  with  counter- 
drainage  through  an  incision  made  anteriorly  just  below  Poupart's 
ligament.  There  is  but  little  hemorrhage  during  the  operation; 
bleeding  vessels  may  be  seized  as  they  are  cut  during  the  progress  of 
the  operation. 

The  soft  parts  are  brought  together  with  interrupted  silkworm- 
gut  sutures,  which  should  pass  deep  through  the  integument,  mus- 
cles, and  periosteum,  closing  the  wound,  except  for  a  space  below 
sufficient  to  allow  the  passage  of  a  thick  tube,  which  should  reach 
upward  as  far  as  the  acetabulum  for  drainage,  or  the  wound  may  be 
packed  with  iodoform  gauze,  or  the  gauze  packing  may  be  combined 
with  the  use  of  a  tube.  Before  closing  the  wound  it  should  be  washed 
out  with  hot  bichloride  solution. 

During  the  operation  one  should  work  as  much  as  possible  with 
the  periosteum  elevator  and  chisel,  cutting  as  few  tendons  as  pos- 
sible with  the  knife.  We  should  strive  to  keep  the  capsule  and  the 
periosteum  or  shell  of  cortex  that  is  separated  from  the  bone,  along 
with  their  attached  tendons,  hanging  together  in  one  continuous 
layer;  so  that,  when  we  are  ready  to  resect,  the  denuded  upper  end 
of  the  femur  lies  in  a  sort  of  sac  which  is  made  of  the  above-named 
structures,  and  Avhich  all  hang  together,  continuous  with  one  another, 
and  it  is  out  of  this  hood  or  sac  that  we  deliver  the  upper  end  of 
the  bone  for  resection.  In  closing  the  wound  the  upper  edges  of 
the  hood  should  be  included  in  the  sutures,  except  the  part  that  is 
left  open  for  drainage. 


AMPUTATIONS,  RESECTIONS,  ETC. 


821 


Plating  for  Fracture  (Lane). — In  fractures  both  simple  and 
compound,  where  the  fragments  cannot  bo  reduced  or  retained  in 
satisfactory  position,  they  may  be  securely  held  with  metal  plates, — 
Lane's  bone  plates.  These  are  provided  in  various  shapes  and  sizes 
for  the  different  bones.  The  plates  arc  applied  directly  to  the  surface 
of  the  fragments.  In  compound  fractures  the  wound  already  present 
may   be   sufficiently    enlarged    to    reach    the    fragments.      In    simple 


Fig.  362.— Plating  for  Fracture  (Lane).    Shows  plate  applied  to  femur  and  secured 
by  screws  to  upper  and  lower  fragments. 

fractures  it  will  be  necessary  to  expose  the  fragments  through  an 
incision  in  the  soft  parts,  the  incision  being  placed  so  as  to  produce 
the  least  possible  damage  to  important  structures.  It  may  be  necessary 
to  freshen  the  ends  of  the  fragments  with  the  chisel,  or  curette,  etc. 
By  means  of  rotation,  extension,  etc.,  the  fragments  are  brought  into 
accurate  apposition.  This  may  be  facilitated  by  employing  the  special 
bone  forceps,  levers,  etc.,  devised  by  Lane.  The  plate  is  applied 
without  detaching  the  periosteum.  Corresponding  to  the  screw-holes 
in  the  plate,  holes  are  drilled  in  the  bone,  first  upon  the  distal  frag- 


822  LOWER  EXTREMITY. 

ment  and  the  screws^  then  driven  in  with  the  screw-driver.  The 
fragments  are  again  brought  into  the  proper  position  and  the  screw- 
holes  drilled  in  the  proximal  fragment  and  the  screws  driven  in. 
The  drill-holes  go  through  to  the  medullary  canal  and  should  cor- 
respond to  the  size  of  the  screws,  neither  too  large  nor  too  small.  The 
wound  must  be  dry,  free  from  oozing.  The  soft  parts  are  sutured 
with  several  layers  of  catgut  sutures,  in  clean  cases  without  drainage, 
and  the  limb  put  up  in  a  plaster-of- Paris  cast. 

If  the  conditions  require  drainage  a  small  rubber-tissue  drain 
may  be  introduced  and  the  limb  placed  in  a  moulded  wire  splint  which 
mil  permit  easy  access  to  the  wound  for  the  purpose  of  removing  the 
drain  after  a  few  days. 

The  operation  must  be  performed  under  the  strictest  aseptic 
precautions  and  with  gloved  hands. 

Foe  Feacture  of  the  Patella. — The  failure  to  obtain  bony 
union  in  cases  of  fracture  of  the  patella  is  due  to  the  interposition 
of  fringes  of  torn  periosteum,  etc.,  between  the  fragments,  to  the 
thick  layer  of  clotted  blood  which  coats  the  edges  of  the  fragments, 
and  to  the  fact  that  we  are  unable  to  bring  the  fragments  into  im- 
mediate approximation  on  account  of  the  distension  of  the  capsule 
of  the  knee-joint  with  blood  and  serum.  The  fragments  of  the  bone 
ride  upon  the  top  of  the  distended  capsule,  and  it  is  not  possible  to 
draw  them  together  until  the  blood  and  serum  have  been  evacuated 
from  the  knee-joint.  After  the  knee-joint  has  been  opened  and  the 
blood  and  serum  cleared  out  it  will  be  observed  that  the  fragments 
can  be  approximated  with  very  little  effort. 

A  slightly  curved  incision  is  made  across  the  front  of  the  knee, 
the  convexity  being  downward.  When  the  very  short  flap  which  is 
thus  marked  out  is  dissected  back,  the  line  of  fracture  through  the 
patella  is  exposed  to  view  and  the  knee-joint  is  opened  between  the 
fragments.  It  will  be  observed  that  the  dense  fibrous  capsule  of  the 
joint  is  torn  to  a  greater  or  less  extent  upon  either  side  of  the  patella 
and  on  a  line  corresponding  to  the  line  of  fracture. 

Any  ragged  edges  of  periosteum  which  overhang  the  edges  of 
the  bony  fragments  and  which  might  get  in  between  them  are 
trimmed  away  with  the  scissors.  Each  fragment  is,  in  turn,  lifted 
up  into  the  incision  with  a  sharp  hook  and  scraped  free  of  blood-clot 
with  the  sharp  spoon.  The  blood  is  cleared  out  of  the  joint  with  dry 
gauze  wipes.     The  joint  should  not  be  irrigated. 

The  edges  of  the  torn  capsule  are  united  with  a  sufficient  number 


AMPUTATIONS,  RESECTIONS,  ETC. 


823 


of  sutures  of  kangaroo  tendon;  usually  two  or  three  sutures  upon 
each  side  will  suffice.  The  suture,  which  is  placed  immediately 
adjacent  to  the  patella,  is  inserted  very  close  to  the  side  of  the  bone. 
When  the  sutures  are  tied  it  will  be  seen  that  the  fragments  of  the 
patella  are  brought  into  very  close  apposition.  Several  sutures  of 
chromic  catgut  may  be  inserted  to  bring  the  edges  of  the  periosteum 


Fig.  363.— Operation  for  Fracture  of  the  Patella.  The  edges  of  the  torn 
capsule  are  brought  together  with  a  suflBcient  number  of  sutures,  thus  bringing 
the   edges  of   the   fragments   into   close  apposition. 

together  along  the  line  of  the  fracture.  No  sutures  are  introduced 
through  the  bony  fragments  themselves.  All  bleeding  must  be  con- 
trolled so  that  the  wound  is  perfectly  dry.  The  incision  in  the  skin 
is  closed  without  drainage,  and  the  limb  placed  in  a  plaster-of-Paris 
cast. 

The  strictest  asepsis  must  be  observed  in  this  operation.    Eubber 
gloves  are  worn  by  the  operator  and  his  assistant.     The  number  of 


821 


LOWER  EXTREMITY. 


assistants  should  be  limited  to  one.  The  parts  are  handled  as  little 
as  230ssible  and  all  oozing  controlled  before  the  incision  is  closed. 
Osteotomy  of  the  Femur  for  Genu  Valg"um — Knock-knee  (Mac- 
ewen). — The  knee  is  somewhat  flexed,  its  outer  side  resting  upon 
a  sandbag.     A  short  longitudinal  incision  is  made  upon  the  inner 


Fig.  364. — Osteotomy  (Macewen).  A.M.,  opening  in  the  adductor  magnus 
through  which  the  femoral  artery  (F.A.)  passes  into  the  popliteal  space. 
Arrow  indicates  point  at  which  the  chisel  is  applied  and  the  dotted  line  the 
plane  of  section  for  bow-legs  and  knock-knee. 


side  of  the  thigh  just  above  the  knee-joint.  It  is  placed  one  finger's 
breadth  in  front  of  the  tendon  of  the  adductor  magnus,  its  loAver 
end  upon  a  line  which  is  drawn  around  the  lower  part  of  the  thigh 
one  finger's  breadth  above  the  upper  border  of  the  external  con- 
dyle;   or  we  may  locate  the  lower  end  of  the  incision  two  fingers' 


AMPUTATIONS,  RESECTIONS,  ETC.  825 

breadth  above  the  inner  condyle  and  one  finger's  breadth  in  front  of 
the  tendon  of  the  adductor  magnus.  The  incision  is  jDrolonged  upward 
for  a  distance  of  4  cm.  and  reaches  to  tlie  bone  through  the  integu- 
ment, vastus  internus  muscle,  and  periosteum. 

The  periosteum  is  separated  from  the  surface  of  the  bone  over 
an  area  sufficient  to  allow  the  application  of  a  broad  chisel,  with 
which  the  bone  is  divided,  in  a  direction  outward  and  slightly  upward. 
The  line  of  fracture  does  not  pass  through,  but  just  above,  the  joint. 
The  deformity  is  then  corrected,  and  the  limb,  including  the  foot, 
placed  in  a  plaster  splint. 

It  is  not  necessary  to  chisel  through  the  entire  thickness  of  the 
shaft  of  the  femur,  but  only  far  enough  to  allow  one  to  gradually  bend 
the  bone  into  position — it  should  not  be  forcibly  fractured  or  bent  into 
position  with  a  sudden  jerk.  The  line  of  fracture  is  placed  above  the 
epiphyseal  line,  and  therefore  this  operation  may  be  done  upon  chil- 
dren and  young  people  without  interfering  with  the  natural  subse- 
quent growth  of  the  femur.  This  operation  may  also  be  done  through 
an  incision  upon  the  outer  aspect  of  the  limb  upon  the  same  level. 


INDEX. 


(The  names  of  arteries,  veins,  nerves,  muscles,  etc.,  are  placed  in  the  Index 
under  the  headings  "Artery,"   "Vein,"  etc.) 


Abbe,  operations  for  stricture  of  oesopha- 
gus,  369. 
Abdomen,  321. 
antero-lateral  wall   of,   323. 
muscles  of,  324. 
aponeuroses  of,   326. 
operations  upon,   339. 
posterior  wall  of,  322. 
regions  of,   330. 
Abdominal  cavity,  321. 
hernia,   352. 
incisions,   340,   477. 
wall,  deep  vessels  of,  329. 
superficial  vessels  of,   324. 
Abscess,    appendicular,   operation   for,   482. 
of  brain,  96,   104. 
of  breast,  301. 
of  cerebellum,  127. 
of  cerebrum,  96,  104. 
extradural,   middle  fossa,   128. 
in  frontal  lobe,  104. 
of  kidney,   659. 
of  liver,  493. 
perinephritic,    569. 
in   temporo-sphenoidal   lobe,   128. 
Acetonjemia,    2. 
Adenectomy,    cervical,   240. 
Aditus  ad  antrum,  114,   120. 
Adrenalin,  21. 
Alimentary  tube,  161. 

Alveolar  process,  lateral  clefts  of,  172,  173. 
Amputation,   of  arm,  731. 
of  breast,  302. 
of  finger,  720,  722. 
of  foot,  Chopart,  778. 
Lisfranc,   775. 
Pirogoff,  782. 
Gunther,  783. 
Le  Fort,   783. 
Syme,  780. 
of  forearm,  727. 
of  leg,   784. 
of  penis,  681. 

of    rectum    (see   "Rectum"), 
of  thigh,  795. 
of  toe,  772. 

of  tongue    (see   "Tongue"). 
Antesthesia,    1. 
chloroform,     1,  8. 
cocain,   11. 
ether,   1,   5. 
ethyl  chloride,  4,  11. 
general,    1. 

incomplete,   4. 
intratracheal,  9,  314. 
local,   11. 
infiltration  method,  13. 
regional,   14. 
Schleich,  13. 
Melzer  and  Auer,  insufflation  method,  9. 
nitrous  oxide,  3. 
regional,  14. 
spinal,  15. 
Anfesthetics,    1. 
administration  of.   5. 
Gwathmey  apparatus  for,  6. 
Analgesia,   by   subarachnoid   injection,    15, 
541. 


Anastomosis,    arterio-venous,    Crile's   can- 
nulse,  30. 
suture   method    (Carrel),    27. 
intestinal  (see  "Intestinal  Anastomosis"). 
Ankle-joint,   779. 
exarticulation  of  foot  at,  780. 
Pirogoff  method,   782. 
Gunther  modification,   783. 
Le  Fort  modification,  783. 
Syme,  780. 
resection  of,   Koenig,   807. 
Langenbeck-Hueter,    803. 
Lauenstein,   809. 
Mikulicz-Wladimirow,    810. 
with    extirpation    of    astragalus,    806. 
Antrum,   aditus  ad,  120. 
of  Highmore,   130. 

to  drain,  148. 
Mastoid,  114. 
to  open  and  drain,   122. 
operations  upon,   122. 
Anus,  artificial,  464. 

operations  upon,   553. 
Aorta,   arch  of,   287. 

thoracic,   292. 
Aortic  valve,  orifice,  286. 
Aponeuroses  of  abdominal    muscles,    326. 
Aponeurosis  of  external    oblique,    325. 
Appendicectomy,    477. 
incisions   for,    477. 
McBurney,   477. 
mid-rectus,  478. 
Appendicitis  accompanied  by  general  peri- 
toneal  infection,   operation,  486. 
Appendicostomy,  487. 
Appendicular  abscess,   operation,   482. 
Appendix  vermiformis,  amputation  of,  477. 
inversion   of,    482. 
inversion  of  stump  of,  after   amputation, 

481. 
ligation  of  stump  of,  without  inversion, 

480. 
surgical  anatomy  of,  460. 
Aquaeductus    Fallopii,    120,    121. 
Arachnoid,  brain,  61. 

of  cord,   338. 
Arch,  mandibular,  163. 

of  aorta,   287. 
Arches,   visceral,   162. 
Arm,  709. 

amputation  of,   731. 
Arteries,   of  scalp,  40. 

of   stomach,   358. 
Arterio-venous  anastomosis,   27. 
with    Crile's   cannulse,   30. 
suture   method    (Carrel),   27. 
Artery,    anterior   tibial,   761. 
ligation  of,  762. 
axillary,   706. 

ligation  of,  716. 
brachial,   709. 

ligation  of,  717. 
common   carotid,   221. 

ligation  of,  230. 
common   carotid,   left,   293. 
deep  epigastric,  329,  597. 
dorsalis  pedis,   761. 
external  carotid,  224. 


(827) 


828 


INDEX. 


Artery,    external   carotid,    ligation   of,   232. 
facial,  129,  137,  225. 
femoral,  754. 

ligation  of,  757,    759. 
inferior  thyroid,  227. 

ligation  of,  235. 
innominate,   293. 
intercostal,    ligation   of,   307. 
internal   carotid,   223. 

ligation  of,  232. 
internal   mammary,   275. 

ligation  of,  307. 
internal  maxillary,   140. 
lingual,   136. 

ligation  of,  262. 
middle  meningeal,   48,   52,   74,  142. 

ligation  of,  74. 
musculo-plirenic,    275. 
obturator,   615,   618. 
popliteal,   760. 
posterior  tibial,   762. 

ligation  of,  765. 
pulmonary,    299. 
radial,  712. 

ligation  of,  719. 
subclavian,   226. 

ligation  of,  233. 
subclavian,   left,  293. 
superior  epigastric,   275,    329. 
superior  hemorrhoidal,   551. 
superior  thyroid,  227. 

ligation   of,   234. 
temporal,   138. 
thyroidea  ima,  220. 
ulnar,  714. 

ligation   of,    719. 
vertebral,   210,   228. 
Ascending  colon,    anatomy  of,   462. 
Asterion,  44. 

Atresia   of  facial  orifices,   171. 
Auditory   canal,    external,   116,   168. 

process,   117. 
Auricle,  116,  168. 

Auriculo-ventricular  valves,   orifices,   287. 
Axilla,   surgical   anatomy  of,   706. 
Axillary  abscess,   incision  for,   709. 
line,  276. 

Back,    332. 

muscles  of,  333. 
Bardeleben,   operation  for  harelip,  188. 
Basedow's   disease    (see    "Thyroidism")- 
Bassini  operation   for  hernia,  618. 
Battle  incision,   343. 
Bevan's  operation  for  undescended  testis, 

630. 
Beyea  operation,   360. 
Big  toe,  exarticulation  of,  772. 
Bile-ducts    (see   "Gall-ducts"). 
Billroth,   extirpation  of  tongue,   269. 

pylorectomy,    386. 
Bladder,   drainage  of,   676. 

incision   of,    for   stone,   674. 

operations   upon,    674. 

puncture  of,    676. 

surgical  anatomy  of,  671. 

suture  of  wounds  of,  38,  676. 
Blandin's  method,  harelip,  187. 
Bone,   division  of,  16. 

plating   of    (Lane),   for  fracture,   38,   821. 

suture  of,  35. 
Bottini,   prostatotomy,   703. 
Bovee,    uretero-ureterostomy,    669. 
Bowel,    suture  of   wounds  of,   36,   417   (see 

"Intestine,"  etc.). 
Brachial  plexus,  213,  708. 
Brain,  56. 

operations  upon   (see   "Head,   operations 
upon"). 

puncture  of,  for  diagnosis,  97. 


Breast,   280. 

amputation    of,    Halsted-Meyer    method, 
302. 

extirpation  of  fibroid  from,   302. 

fibroid   of,    302. 

incisions   for   abscess   of,   301. 

lymphatics  of,   281. 

operations  upon,  301. 
Bregma,  42. 

Brewer's   transfusion   tubes,   32. 
Broca's  convolution,   60. 
Brophy's    operation    for   cleft    palate,    194. 
Bruns  method,  formation  of  lips,  198. 
Bunion,   operation   for,   773. 

Caecum,   resection   of,   473. 

surgical   anatomy   of,    460. 
Canal,    crural,    60S. 

external  auditory,  116. 

Hunter's,    756. 

inguinal,    594. 

Vidian,   142. 
Carden    amputation    of   leg,    792. 
Cardiorrhaphy,    309. 
Carotid  triangle,   inferior,  209. 

superior,   210. 
Carrel's   arterio-venous   anastomosis,    27. 
Castration,   648. 
Cavernous   sinus,    49,    56. 
Cavum  Meckelii,   52. 
Cerebellar   abscess,    127. 
Cerebellum,  61. 

exposure   of.    Gushing,   92. 
Krause,  94. 
Cerebro-spinal  fluid,  61,  338. 
Cerebrum,  58. 

methods    to    locate    various    areas,    (see 
"Cranio-cerebral    topography"). 

operations  upon   (see  "Head,   operations 
upon"). 
Cervical  fascia,   202. 

lymph  nodes,   229. 
excision  of,  240. 

sympathetic,  228. 
resection  of,   237. 
surgical  anatomy  of,  228. 
Chassaignac,   tubercle  of,  222,  257. 
Cheeks,  132. 
Chest,   fascia  of,  274. 

aspiration   of    (see   "Thoracentesis"). 

tapping  of   (see  "Thoracentesis"). 
Chest  wall,  muscles  of,  274. 

resection   of  part  of,   318. 
Chetwood,   prostatotomy,   705. 
Chiene's    method,     cranio-cerebral    topog- 
raphy,   66. 
Chloroform,   1. 

administration  of,   8. 
Cholecystectomy,    508. 
Cholecyst-enterostomy,    512. 
Cholecysto-colostomy,    517. 
Cholecysto-duodenostomy,   512. 
Cholecysto-jejunostomy,    515. 
Cholecystostomy,  503. 
Cholecystotomy,  501. 
Choledocho-duodenostomy,   523. 
Choledochotomy,  518. 

transduodenal,   523. 
Chopart    amputation,    788. 

joint,   771. 
Chorda  tympani,  121. 
Circumcision,   680. 

with   clamp,    681. 
Cisterna   basalis,    64. 

chiasmatis,    64. 

interpeduncularis,   64. 

magna,    64. 

pontis,    64. 
Cisternse   subarachnoidales,    64. 
Clavicular  region,  278. 


INDEX. 


829 


Cleft  of  alveolar  process,  172,  173. 

palate,   170,   172,   175. 
operation  for,   1S9. 
Brophy's,   194. 
Clefts,    lateral    nasal,   178. 

lateral,   of  upper  lip  (see  "Harelip"). 

median,   of  upper  lip,   177. 

oblique   faeial,    1G7,    178. 

of  lower  lip,   lower  jaw  and  tongue,  179. 

orbito-nasal  {see  "Oblique  faeial  clefts"). 

transverse  facial,   1G8,   179. 

visceral,   162. 
Cocain  anresthesia,  11. 
infiltration   method,    13. 
regional,   14. 
Schleich  method,   13. 

subarachnoid  injection  of,  15,  541. 
Coccyx,   546. 
Colles's   ligament,    592. 
Colon,     resection    of    (see    "Resection    of 
CcPcuni"    and    "Sigmoid    flexure"). 

surgical  anatomy  of,   460. 
Colostomy,   464. 

left  iliac,   465. 
Combined     operation     upon     rectum     (see 

("Rectum"). 
Common  bile-duct,  406,  491. 

drainage  of,  521. 

incision    into,   518. 

operations   upon,   518. 

removal  of  calculi  from,   518. 
through    duodenum,    523. 

surgical    anatomy    of,    491. 

suture   of,    521. 
Congenital      deformities      of      face       (see 
"Face"). 

hernia    (see   "Hernia"). 
Conjoined  tendon,   326,   596. 
Connell   suture.   429. 
Conus  terminalis,  338. 
Cooper,  pubic  ligament  of,  604,  606,  614. 
Corning,   spinal   injection,   541. 
Corpora  cavernosa,   677. 
Corpus  spongiosum.   677. 
Costal  cartilages,   273. 
Costo-coracoid  membrane,  278,  280,  707. 
Cotting  operation.   775. 
Cowper's  gland.   6S6. 
Craniectomy,   100. 

for  idiocy,   100. 
Cranio-cerebral   topography,   65. 

Chiene's  method,   66. 

Kocher's  69. 

Kronlein's,    67. 
Craniotomy,   82. 

for  abscess  of  brain,^  96. 

for  cyst,  tumor,  90. 

for  epilepsy,  91. 

to  expose  cerebellum,  92. 

to  expose  cerebrum,   82. 

to  expose  motor  area.   84. 

osteo-tegumentary   flap   method,   82. 
Cribriform  fascia,  604,  753. 
Cricoid  cartilage,   216. 
Crico-thyroid  membrane,  217. 
Crico-tracheotomy,  245. 
Crile's  arterio-venous  anastomosis,  30. 

canuulfe.    30. 
Crural  canal,  608. 

ring,   608. 
Cushing,   decompression,   80. 

extirpation    Gasserian    ganglioil,    109. 

suture,    37. 
Cystic  duct,  491. 

incision  into,   517. 
Cysticotomy,  517. 
Cystotomy,   suprapubic,   674. 


Dartos,   636. 

Dawbarn,  inversion  of  stump  of  appendix, 

481. 
"Dead   space,"   mesenteric,   410. 
Decompression,  79. 

cerebellar,   82. 

cerebral,   80. 

Cushing.  80. 
Deformities      of      face,      congenital      (see 

"Face"). 
Depressed    fracture    of    skull,    trephining 

for,  72. 
Descending  colon,   anatomy  of,   463. 
De  Vilbiss  bone  forceps,   77. 
Diaphragm,    276.   321. 

uro-genital,   549.    6S6. 
Dieffenbach's   Wellenschnitt,   184,   201. 

resection   of  rectum,   564. 
Dieffenbach-Jaesche    operation    for    lower 

lip,  197. 
Dilatation   of  sphincter,  553. 
Diploe,   41. 
Dorsal   section,   679. 

Roser   method,   680. 
Douglas,   pouch  of,   548. 

semilunar  fold   of,   328. 
Doyen,   burr,  70,  86. 

chisel,   90. 

forceps,  393. 
Drum  of  ear,   117,   118,   168. 

paracentesis  of,  122. 
Dubrueil.    exarticulation   of   hand,    726. 
Duct,  common  bile-,  406,  49i. 

cystic,   491. 

ejaculatory,  638,  695. 

hepatic,    491. 

pancreatic,    406,   527. 

Santorini,   528. 

Stenson's,    133,    137. 

tear,   167. 

thoracic,   226. 

thyro-glossal,   135,  170. 

Wharton's,  136,  211. 

Wirsung,  527. 
Ductus  communis  choledochus,  491. 
Duodenotomy  for  inpacted  gall-stones,  523. 
Duodenum,    406. 

mobilization  of,   438. 
Dura   mater,   of  skull,   53. 

of   spinal   cord,    338. 

venous   sinuses   of,   54. 

Ear,    development  of,   116,   168. 

middle,  118. 

surgical  anatomy  of.  113,  116. 
Ear-drum,   117,   118,   168. 

paracentesis   of,   122. 
Edebohls  decortication  of  kidney,  665. 

inversion  of  appendix,   482. 
Ejaculatory  ducts,   638.   672,  695. 
Elbow,    space    in   front   of,    710. 
Elbow-joint,  exarticulation  of  arm  at,  730. 

resection  of.   744. 

surgical    anatomy   of,    728. 
End-to-end    anastomosis    (see    "Intestinal 

anastomosis"). 
End-to-side    anastomosis    (see    "Intestinal 

anastomosis"). 
Ensiform  cartilage,  272. 
Bnterectomy,   421. 

Entero-anastomosis   (see  "Intestinal  anas- 
tomosis"). 
Enterorrhaphy,   416. 

for  gun-shot  and  stab  wounds,  416. 

for  typhoid   perforation,   419. 
Enterostomy,  412. 
Enterotomv,  411. 
Epididymis,    638. 
Epigastric  hernia,   352. 
Epilepsy,  craniotomy  for,  91. 


830 


INDEX. 


Esmarch,     exarticulation     of     arm     at 
shoulder-joint,    737. 
bandage,    17. 
Estlaender,   thoracectomy,    318. 

method,   restoration  of  lip,  200,   201. 
Ether,  1. 

administration  of,   5. 
Ethyl  chloride,  4,  11. 
Eucain,   12. 

Eustachian  tube,  122,  134,  168. 
Exarticulation    of    arm    at    shoulder-joint, 
deltoid  flap,   739. 
■with    Esmarch    constrictor,    737. 
Spence  method,  735. 
of  big  toe,   772. 
of  finger,  720. 

of  foot,    at   ankle-joint,    Pirogoff,    782. 
Gtinther   modification,    783. 
Le   Fort   modification,    783. 
Syme,   780. 
of  forearm  at  elbow-joint,   730. 
of  hand,    Dubrueil,    726. 

at    carpo-metacarpal    articulation,    723. 
of  leg.    Garden,   792. 
Gritti-Stokes,    794. 
Stephen  Smith,  790. 
of  little  toe,  773. 

of  thigh  at  hip-joint  (Wyeth),  800. 
with   preliminary   ligation   of   common 
femoral,   803. 
of  toes,   772. 
Excision  of  joints   (see  "Resection"). 
Exophthalmic   goitre   (see   "Thyroidism"). 
Extradural  abscess,   128. 

Face,   classification  of  deformities  of,   172. 
congenital   deformities   of,    161,    171. 
in    which    first    visceral    arch    is    con- 
cerned, 179. 
in   which    frontal    plate    is    concerned, 
172. 
development  of,   161. 
operations  upon,  143. 
side    of,    136. 
skeleton  of,   130. 
surgical  anatomy  of,  129. 
Facial  cleft,  oblique,  167,  178. 

transverse,   168,   179. 
Falciform  process,   604,   753. 
Fallopii,    aquaeductus,    120,    121. 
Falx  cerebelli,  54. 

cerebri,   54. 
Fascia,   anal,   547,   689. 
cremaster,  636. 

cribriform    (cribrosa),    604,    753. 
deep  cervical,   202. 

connective   tissue  spaces  beneath,   204. 
deep  perineal,  549,   686,  687. 
endoabdominalis,    328. 
endothoracica,    274,    322. 
lliaca,   328,   326,  605,  614. 
lata,   604. 
iliac  portion  of,   604. 
pubic  portion  of,  604. 
lumbar,   328,   335. 
obturator,    687. 
pectineal,  604. 
pelvic,  328,  547,  549,  688. 
perineal,    deep,   549,   686,   687. 

superficial,    683. 
spermatic,   591,   636. 
superficial,   of  groin,   590. 
temporal,   41. 
transversalis,   328,  596. 
Fasciae,   of  thorax,  274. 
Fat  necrosis,  508. 
Fauces,  isthmus  of,  133. 

pillars  of,   134. 
Femoral  hernia,  615  (see  "Hernia"), 
operation   for,   629. 


Femoral   region,    604*  608,   612. 
anterior,  753. 

sheath,   606,   756. 

space,  606,  614. 
Fenger's  incision,   361,  364. 
Filum   terminale,   338. 
Finger,   exarticulation  of,   720. 

at  metacarpo-phalangeal  joint,  722. 
Finney  operation,   372. 
Fissure  in  ano,  551. 

longitudinal,  58. 

parieto-occipital,   59,  65. 

Rolando,  58,  65.  ■ 

sphenoidal,   48. 

Sylvius,   59,   65. 
Fistula   in   ano,    553. 

operation  for,  554. 
Fontanelle,   anterior,   42. 

posterior,    42. 
Foot,   amputation  of,  Chopart,  778. 
Lisfranc,   775. 

exarticulation  of,   Pirogoff,  782. 
Giinther  modification,   783. 
Le  Fort   modification,    783. 
Syme,   780. 

surgical  anatomy  of,  770. 
Foramen   caecum,   135,   170. 

infra-orbital,   130. 

lacerum  anterius  (sphenoidal  fissure),  48. 
medium,  46. 
posterius,  53. 

Majendi,  53. 

obturator,  615. 

ovale,   48,   120. 

rotundum,   48,   120. 

spinosum,   48. 

stylo-mastoid,  121. 

of  Winslow,  493. 
Forcipressure,   22. 

Forearm,    amputation    through,    727. 
Forebrain,    vesicle    of,    58,    162. 
Fossa,  anterior,  of  skull,  45. 

cruralis,   612. 

infraclavicular,   279. 

ischio-rectal,   684. 

mastoidea,    115. 

middle,    of   skull,   46,    105. 

posterior,  of  skull,  53. 

spheno-maxillary,   141. 

Mohrenheim,   279. 

zygomatic,   140. 
Fovea  inguinalis   externa,   610. 
interna,  610,  612. 

supravesicalis,  610,   612. 
Fowler,   pleurectomy^  319. 
Frontal   plate   or  process,   164,    172. 

sinus,  44. 
trephining  of,   101. 
Killian,   102. 

Gall-bladder,   aspiration  of,  501. 
excision  of,   508. 
incision  into,  501. 
operations  upon,  501. 
surgical  anatomy  of,  490. 
Gall-duct,    common    (see    "Common    bile- 
duct"). 
Gall-ducts,    operations   upon,   517. 

surgical  anatomy  of,   490. 
Ganglion,  Gasserian,  49. 

extirpation   of,    Hartley-Krause,    105. 
Gushing  method,  109. 
Rose-Andrews,    111. 
Meckel's  143. 
Gasserian   ganglion    (see  "Ganglion"). 
Gastrectomy,   384. 
complete,  400. 
partial,   384. 
Billroth,    386. 
Hartmann,   393. 


INDEX. 


831 


Gastrectomy,    partial,    Kochcr,   390. 

Mayo,  398. 
Gastric   ulcer,  infolding  for,   364. 
for  hemorrhage    from,    366. 
for  perforation   of,   381. 
Gastro-duodenostomy,    438. 
Finney,    372. 
Kocher,   438. 
Gastro-enterostomy,    437. 
Gastro-gastrostomy,  382. 
Gastro-jejunostomy,    438. 
anterior,    440. 
clamp  method,  443. 
suture  method,  440. 

Jaboulay  and  Braun  modification,  444. 
Woelfler,   440. 
posterior,   446. 
clamp  method,  450. 
Czcriiy,   449. 
von  Hacker,  446. 
Mayo,    450,    454. 

■with   McGraw   rubber  suture,   456. 
with   Murphy   button,   455. 
without  a  loop,   suture  method,   446. 
Roux,    458. 
"vicious   circle"    after,    444. 
Gastroplasty,   381. 
Gastroplication,   362. 
Gastrorrhaphy,    380. 
Gastrostomy,    375. 
Kader,   379. 

Ssabanajew   and   Franck,   376. 
Witzel,  376. 
Gastrotomy,   364. 
for  bleeding'  ulcer,   366. 
for  foreign  body,  364,  366. 
for  stricture  of  oesophagus,   369. 
Genu  valgum,   osteotomy  for,  824. 
Genua    inferior    and    superior,    fissure    of 

Ronalds,  59. 
Gimbernat's  ligament,  594,  609,   614. 
Glabella,    43. 
Gland,    Cowper's   686. 
mammary,   280. 
parathyroid,    220. 
parotid,  137. 
prostate,  688,  692. 
sublingual,  135. 
submaxillary,   211. 
thyroid,    219. 
Glands,    cervical,   229. 
extirpation   of,   240. 
of   groin,   591. 
Gluteal  region,  750. 
Goitre,   operations  for,  254. 

exophthalmic    (see    "Thyroidism"). 
Gritti-Stokes  amputation  of  leg,  794. 
Groin,  lymphatic  glands  of,  591. 
superficial   fascia  of,   590. 
surgical   anatomy  of,   590. 
Gubernaculum  of  Hunter,  599. 
■  Giinther    modification    of    Pirogoff    ampu- 
tation,   783. 
Gwathmey  anaesthesia  apparatus,   6. 

Hagedorn  operation  for  harelip,  185. 

Hallux   valgus    (see    "Bunion"). 

Halsted  operation  for  inguinal  hernia,  626. 

suture,   37. 
Halsted-Meyer  amputation   of  breast,   302. 
Hammer-toe,   operations  for,  774. 
Hand,    715,    719. 

exarticulation  of,  723. 
Dubrueil,    726. 

incision   into,   716. 

nerve-supply  of,  716. 

surgical   anatomy  of,   715,   719. 
Harelip,   167,   173. 

with  advanced  intermaxillary  bone,   op- 
eration for,  187. 


Harelip,    Bardoleben    operation    for,    188. 
Blandin,    187. 

von   Graefe   operation   for,   181. 
Hagedorn,   185,   187. 
Malgaigne,   182. 
Mirault,   183,  186. 
Nelaton,   182. 
operations  for,  179. 
for  complete,  184. 
for  incomplete,   181. 
"Wellenschmitt    (Dieffenbach),    184,    201. 
Hartley  chisel,  74. 
Hartley-Krause  operation,  105. 
Hartmann   forceps,    393. 

gastrectomy,   393. 
Head,    40. 
operations  upon,   70. 
surgical   anatomy  of,   40. 
Heart,    284. 
operations   upon,   307. 
outlines  of,   upon   chest-wall,   285. 
suture  of  wounds  of,   309. 
tamponade,   309,   310. 
Heidenhain,  method  of  controlling  hemor- 
rhage,  85. 
Heinecke-Mikulicz    pyloroplasty,    370. 
Hemorrhage,    16. 
artificial    arrest   of,    17. 
by  direct;  means,   20. 
by  indirect   means,    17. 
means  to  arrest,   17. 
natural   arrest  of,   17. 
transfusion  for  severe,  27. 
treatment  of  severe,   24. 
by  intravenous  saline  infusion,  24. 
by  transfusion   of   blood,   27. 
Hemorrhoids,    internal,   bleeding,   552,   556. 
external,   itching,   551,  555. 
operations   for,   555„ 
clamp   and   cautery,   559. 
ligation   and  excision,   557. 
Henle's  spine,  116. 
Hepatectomy,  496. 
Hepatic  duct,  490,  491. 

incision  of,    for  stone,   518. 
Hepaticotomy,   518. 
Hepatotomy,  493. 
for  abscess,    493. 
for  hydatid  cyst,   495. 
Hernia,    460,    590. 
diaphragmatic,    322. 
femoral,    608. 

operation  for,  629. 
Inguinal,   598. 
acquired,   600,   602. 

operation   for,   618. 
congenital,   600,   602,  612. 

operation   for,   625. 
direct   (internal),  598,   612. 

operation   for,   626. 
external    (oblique.   Indirect),  598,  612. 

operation   for,   618. 
Holsted's   operation   for,    626. 
indirect   (oblique,   external),  598,  612. 
infantile  or  encysted,  602. 
internal    (direct),    598,    612. 

operation  for,  626. 
oblique    (external,    indirect),    598,    602, 
612. 
operation   for,    618. 
operations  for,   615. 
strangulated,   operation   for,   615. 
umbilical,  347. 
congenital,    347. 
funiculi   umbilicalis,   347. 
infantile,    348. 
In  adults,  349. 
Mayo  operation  for,  350. 
operations  for,   347. 
into  umbilical  cord,   347. 


832 


INDEX. 


Hernia,    ventral,    352. 

abdominal,   353. 

diastase  of  recti,   353. 

epigastric,    352. 

post-operative,   354. 

varieties  of,  352. 
Herniotomy,    615. 
Highmore,   antrum  of,  130. 

operations  to  drain,  148. 
Hip-joint,    exarticulation   of  thigh  at,   800. 
resection   of,    817. 
surgical   anatomy  of,   797. 
Holden's  line,   130. 
Horsley's   wax,    88. 
Houston,   valves  of,   548,    550. 
Hudson's  trephine,   71,   86. 

bone-forceps,    77. 
Hunter,    gubernaculum   of,    599. 
Hunter's   canal,    756. 
Hydrocele,    operations  for,    642. 
Hyoid   bone,    214. 
Hyrtl,   bloodless  zone  of,   652. 

Idiocy,   craniectomy  for,  100. 
Ileo-Cffical   valve,    462. 
Ileo-colostomy,   475. 
Ileum,    407. 
Iliac  fascia,   328,   336,  605. 

portion  of  fascia  lata,  604. 
Ilio-pectineal  ligament,   606,   614. 
Ilio-psoas  space,   606. 
Inferior  longitudinal   sinus,    55. 
Inferior  maxilla   (see   "Lower  jaw"),  131. 
Inferior  maxillary    branch    of    fifth   nerve, 
51,   142. 
injection  of,   for  pain,   161. 
Infraclavicular   region,    279. 
Infrahyoid  region,   216. 
Infundibular  process,   596,   597,   599,   610. 
Infundibulum,  44. 
Infusion,  intravenous,  24. 
Ingrowing   toe-nail,    operations   for,    775. 
Inguinal   canal,    594. 
hernia,  598. 
region,   591,   608. 
ring,   internal,   596. 
external,  325,  592. 
Inion,    43. 
Intermaxillary  bone,   169,   174. 

operation  for  harelip  with  advanced,  185. 
Intestinal     anastomosis,     large     Intestine, 
end-to-end,    474. 
end-to-side,   475. 
lateral,   side-to-side,  474. 
small   intestine,    end-to-end,   423. 
Connell,   429. 
McGrath,    423. 
Mounsell,   427. 
with    Murphy   button,    431. 
lateral,  433. 
side-to-side,   433. 
with  clamps,  436. 

with  McGraw's   rubber  suture,   437. 
with  Murphy   button,    436. 
with  suture,   433. 
Intestine,   large,   blood-supply  of,   464,   583, 
584. 
operations   upon,   464. 
surgical  anatomy  of,  460. 
small,  blood-supply  of,  410. 
operations   upon,   411. 
resection   of,   421. 
surgical  anatomy  of,  406. 
suture  of  gun-shot    and    stab    wounds 

of,    36,    411,    417. 
suture  of  typhoid   perforations,    419. 
Intracranial    hemorrhage,    74. 

trephining  for,   74. 
Intratracheal  anaesthesia,  9. 
Intravenous  saline  infusion,  24. 


Ischio-rectal  abscess,  684. 
fossa,   684. 
region,   683. 

Jaboulay   and   Braun,    gastro-jejunostomy, 

444. 
Jaw-bone,   lower   (see  "Lower  jaw"). 

upper  (see  "Upper  jaw"). 
Jejunostomy,    414. 
Jejunum,  407. 
Jonnesco  operation,   237. 
Junker   chloroform   apparatus,   9. 

Kader,  gastrostomy,  379. 
Kidney,  abscess  of,   operation  for,  659. 
absence   of   one,    650. 
capsule  of,   650,   652. 
decortication  of,   665. 
extirpation  of,   662. 
abdominal,   663. 
lumbar,  662. 
fixation  of,  665. 
floating,   665. 
incision  into,  659. 
for    stone,    661. 
movable,   655. 
operations  upon,  655. 
pelvis  of,  653. 
sinus   of,    651. 

stone  in,   operation  for,   661. 
surgical  anatomy,   322,   650. 
Killian  operation  on  frontal  sinus,   102. 
Knee-joint,  amputation  of  leg  at.  Garden, 
792. 
Gritti-'stokes,   794. 
Stephen  Smith,  790. 
bursse  adjacent  to,   789. 
resection   of,    812. 
surgical  anatomy  of,   787. 
Knock-knee,   osteotomy  for,  824. 
Koenig,    resection   of   ankle-joint,    807. 
Kocher,   amputation   of  tongue,  231,   262. 
craniometer,    68. 
gastro-duodenostomy,   438. 
method    of    cranio-cerebral    topography, 

69. 
mobilization  of   duodenum,   438. 
pylorectomy,   390. 
Kousnetzoff  and  Pensky,  control  of  hemor- 
rhage from  liver,  496. 
Kraske,    amputation    of   rectum,    581. 
resection   of  rectum,   574. 
sacral   route  to   reach   rectum,   573. 
Krause,     permanent    drainage    of    lateral 
ventricles,    98. 
exposure  of  cerebellum,  94. 
extirpation  of  Gasserian  ganglion,  105. 
Kredel's  blocks,  85. 
Kronlein's  operation,   157. 
method    of    cranio-cerebral    topography, 
67. 
Kiistner  and  Pfannenstiel  incision,   343. 

Lambda,    42. 
Laminectomy,  537. 
Lane's   plates,    36,    821. 

operation  for  fractures,   36,   831. 
Langenbeck,    extirpation   of  tongue,   268. 

formation   of  lower  lip,   199. 

incision  for  resection  of  upper  jaw,  144. 
Langenbeck-Hueter,     resection    of    ankle- 
joint,    803. 
Laparotomy,   339. 

incision,  340. 
closure  of,   345. 
drainage,   346. 

preparation  of  patient,   339. 
Large    intestine    (see    "Intestine"). 
Laryngeal  region,   218. 
Laryngectomy,   250. 


INDEX. 


So'6 


Laryngotomy,    transverse,   248. 
Larynx.   218. 
e.xtirpation   of,   250. 
half  of,    extirpation  of,   254. 
Lateral  anastomosis  (see  "Intestinal  anas- 
tomosis"), 
implantation    after   resection   of   C£ecum, 

475. 
lithotomy,  692. 
nasal   clefts.   178. 

process,  165. 
pectoral   region,   282. 
sinus,    53,    55,    113. 
sternal    line,    276   . 
Lauenstein,    resection    of   ankle-joint,    809. 
Le   Fort,    exarticulation   of   foot,    783. 
Leg,  761. 
amputation   of,   784. 

with  lateral  hooded  flaps,  784. 
exarticulation  of,  at  knee-joint.   Garden, 
792. 
Gritti-Stokes,  794. 
Stephen   Smith,   790. 
varicose    veins    of.    766. 
operations  for,  766. 
Lembert  suture,  37. 
Ligament,    Colles's    (triangular),    592. 
Cooper,   pubic,   of,  604,  606,  614. 
falciform,    329,    488. 
gastro-colic,  357,  358. 
gastro-henatic,  357,  406. 
gastro-splenic,   534. 
Gimbernat's,   594,   609,   614. 
hepatico-duodenale,  406,   491. 
ilio-pectineal.    606,    614. 
Pouparfs,    325.    592,    612. 
pubic,    of   Cooper,    604,    606,    614. 
round,  of  liver,  329,  490. 
uterine,    594,    599,    600. 
rhomboid,    279. 

sacro-sciatic,   greater  and  lesser,   751. 
of  Treitz,   407. 
triangular   (Colles's),    592. 
triangular  (perineum),  549,  686,  687. 
Ligamentum  arcuatum  internum,  321,  336. 
externum,   321,  335. 
dentatum,   338. 
nucha,  202. 

transversum  pelvis,   686. 
Ligation  of  arteries   (see  "Artery"). 

preliminary,  to  control  hemorrhage,  19. 
of  varicose   veins   of  leg,   766. 
Line,  axillary,  276. 
lateral  sternal,  276. 
mammary,   276. 
midsternal,   276. 
parasternal,    276. 
scapular,   276. 
Linea  alba,    325. 

semilunaris,    323,   325. 
Lingual    triangle,    212,    263. 
Lip,   lower,   clefts  of,   179. 
excision  of,   196. 
restoration   of,   196. 
Brun's  method,  198. 
Dieffenbach-Jaesche,    197. 
Estlaender,  200. 
Langenbeck,   199. 
upper,   operations   upon,   201. 
lateral    clefts   of,    172. 
median   clefts  and  notches  of,   177. 
restoration  of,  201. 
Lips,    operations   upon,    196. 
surgical  anatomy  of,  132. 
Lisfranc.   amputation  of   foot,   775. 

of   rectum,    567. 
Lithotomy,   lateral,   692. 

median.  691. 
Little-toe,   exarticulation  of,   773. 
Liver,    cirrhosis   of,    operation   for,    500. 


Liver,   for  abscess  of,  493. 

for  hemorrhage  from,   496. 

for  hydatid   cyst  of,   495. 

incision   into,   493. 

injuries   of,   499. 

operations  upon,  493. 

resection  of  part  of,  496. 

round   ligament  of,   329,   490. 

surgical   anatomy  of,   488. 
Lloyd,    thoracotomy,   317. 
Local   anaesthesia,   11. 
Longitudinal  sinus  (see  "Sinus"). 
Lower  jaw,   131. 

median   clefts   of,   179. 

resection   of  half  of,    149,   231. 
of  entire   body   of,    153. 
of  half  of  body  of,  152. 
of  part  of  body  of.  154. 
Ludovici,   angle  of.   273,   277. 
Lumbar  puncture,   541. 
Lumbard's    nasal    tubes,    7. 
Lung,   300. 

decortication   of.    319.  * 

limits  of,  300. 

root  of,   209. 
Lymph-nodes,    cervical,    299. 
excision  of,   240. 

Macewen,   osteotomy,  824. 

Macrostoma,  168,  179. 

-Vladelung's   operation    for    varicose   veins, 

769. 
Majendi,  foramen  of,  63. 
Malgaigne  operation  for  harelip,   182. 
Mammary   line,   276. 

gland,    280. 
amputation    of,    302. 
operations   upon,    301. 

region,   280. 
Mandibular  arch,   163. 
Marion,    osteo-tegumentary   flap,   86. 

separator,  88. 
Mastoid  antrum,   114,  123. 

to   open   and   drain,    122. 

operations  upon,   122. 

process,    114. 

region,    surgical   anatomy   of,   113. 
Maxillary     bone,      inferior     (see     "Lower 
jaw"), 
superior    (see    "Upper    jaw"). 

process,    inferior,    165. 

superior,    164,   167. 

Maydl,   jejunostomy,   414. 

Mayo,  gastrectomy,  39S. 

gastro-jejunostomy,    450,   454. 

operation  for  umbilical  hernia,   350. 
McBurney   incision,   343,   477. 

point,  461. 
McGrath,    end-to-end   anastomosis,   423. 
McGraw   intestinal   anastomosis,   437. 

rubber    suture,    gastro-jejunostomy,    456. 
Meckelii,  cavum,  52. 
Meckel's  ganglion,   143. 
Median    lithotomy,    691. 
Mediastinum,    282. 

contents   of.    282. 
Membrana  tympani,   117,   118,  168. 

paracentesis,   122. 
Meningocele,    42,    43. 
Mesentery,  408. 

"dead   space"    of,    410. 

wounds  of,  411,   418. 
Metacarpo-phalangeal  joints,   720. 

exarticulation   of  finger  at,   723. 
Microcephalia,   craniectomy   for,   100. 
Microstoma,  171,   179. 
Middle  ear.  118. 

fossa  of  skull,  46,  105. 
extradural  abscess  in,  128. 

meningeal  artery,   hemorrhage  from,  74. 


53 


834 


INDEX. 


Middle   nasal   process,    165. 
Mid-rectus   incision,    478. 
Midsternal   line,   276. 

Mikulicz-Wladimirow    resection    of   ankle- 
joint,   810. 
Mirault   operation   for   harelip,   183. 
Mitral   valve,    position   of,    287. 
Mohrenheim,  fossa  of,  279. 
Morgagni,   columns  of,   551. 
Morison,    space   of,    493. 
Motor  area,   60. 

to   expose,   84. 
Mounsell,    end-to-end   anastomosis,   427. 
Mouth,    132. 

Mouth-gag,   Whitehead,   189. 
Murphy    button,    cholecysto-duodenostomy 
with,   514. 
gastro-jejunostomy  with,    455. 
intestinal    anastomosis    with,    431,    436. 
Muscle,   buccinator,   132. 

bulbo-cavernosus,   684. 

compressor   urethrae,    686. 

cremaster,   594,   636. 

erector   spinas,    334. 

external   oblique,   334. 
aponeurosis  of,  325,  592. 

external   pterygoid,   140. 

gluteus   maximus,    750. 

iliacus,    336,    605. 

ilio-psoas,    336,   605. 

internal  oblique,  325,  596. 

internal   pterygoid,    143. 

latissimus   dorsi,    333. 

levator   anguli  scapulae,   334. 

levatores   ani,    549,   687. 

masseter,    137. 

mylo-hyoid,    134. 

occipito-frontalis,  40. 

pectoralis  major,  278. 

pectoralis   minor,    278. 

platysma,  206. 

psoas,    336,   605. 

quadratus  lumborum,   335. 

rectus,  326. 

rhomboideus,    334. 

sphincter  ani,  547,  549,  550,  683. 
dilatation  of,  553. 

splenius,   334. 

sterno-hyoid,  217. 

stferno-mastoid,  205. 

sterno-thyroid,    217. 

subclavius,   278. 

subcostales,    274. 

temporal,  41. 

transversalis   abdominis,    326,   596. 

transversus  perinei,   685. 
deep    (compressor    urethrae),    686. 

trapezius,    333. 

triangularis  sterni,  274. 
Muscles,    intercostal,    274. 

of  back,    333. 

of  chest,   274. 

Nasal  clefts,  lateral,  178. 

process,    lateral,    165. 
middle,  165. 
Nasion,    43. 
Navel,    323. 
Neck,   back  of,  205. 

blood-vessels   of,    221. 

front  of,   214. 

operations  upon,   230 

side  of,   205. 

surgical  anatomy  of,   202. 
Nelaton   operation   for   harelip,    182. 
Nephrectomy,   662. 

abdominal,   663. 

lumbar,   662. 
Nephrolithotomy,    661. 
Nephropexy,   655. 


Nephrotomy,    659. 
Nerve,   anterior  crural,  757. 
anterior  tibial,   762. 
auriculo-temporal,  138,   142. 
cervical  sympathetic,  228. 

resection   of,   237. 
facial,    121,    130,    138. 
facio-hypoglossal    anastomosis,    236. 
fifth,   50. 
division    of    branches    of,    at    base    of 
skull,    Kronlein-Liicke,   157. 
of  peripheral  branches,   158. 
inferior  maxillary  branch,  51,  142. 

injection   of,   161. 
injection  of  branches  of,   159. 
ophthalmic  branch,  51. 

injection  of,   161. 
operations  upon  branches  of,  158. 
superior   maxillary   branch,    51,   142. 
injection   of,   160. 
glosso-pharyngeal,    136,    223. 
gustatory  (lingual),  1.36,  143. 

division    of,    159. 
hypoglossal,   136,  211,  224,   263. 
inferior    dental,    division    of,    158. 
median,  715. 
musculo-spiral,   715. 
pneumogastric,  288. 
posterior  tibial,   765. 
sciatic,    stretching,   751. 
spinal   accessory,   212. 
suture   of,    35,    749. 
sympathetic,  cervical,  228. 
resection  of,   237. 
surgical  anatomy  of,  228. 
trifacial    (see  "Fifth"), 
ulnar,   715. 

vagus  (pneumogastric),  288. 
Nerves,    inferior   recurrent  laryngeal,   218, 
219,    227,    289. 
of   neck,    superficial,    208. 
of  tongue,  136. 
phrenic,   289. 
pneumogastric,  288. 
Neural   tube,    161. 
Nipple,   280. 
Nitrous   oxide,   3. 
Novocain,    12. 

Oblique  facial   clefts,   167,    178. 
Obturator  fascia,  687. 

foramen,    615. 
Occipital  triangle,  212. 
aUsophago-duodenostomy,     403. 
CEsophago-jejunostomy,   403. 
CEsophagostomy,   262. 
GEsophagotomy,    external,    260. 
(Esophagus,   218,   290. 

relations  of,  291. 

stricture   of,    operation    for,    369. 
Olfactory   groove,   166. 
Omentopexy,  499. 
Omentum,   gastro-splenic,   358,   403,   534. 

great,    358. 

lesser,   357,   406. 
Ophthalmic  division    (see  "Nerve,   fifth"). 
Oral  pit,   163. 

plate,   162. 
Orbito-nasal   cleft,   167. 
Osteo-tegumentary    flap,    82. 
Osteotomy   for   knock-knee,    824. 
"Outside   serous   ring"   suture,   442. 

Pacchionian  bodies,   64. 
Palate,  134,   135. 
cleft,    170,    172,    175. 
operation    for,    189. 
Brophy's,   194. 
formation  .of,   169. 
Pampiniform  plexus,   636. 


INDEX. 


835 


Pancreas,  cysts  of,  530. 

fat  necrosis,   528. 

injuries  to,  529. 

operations  upon,  528. 

surgical  anatomy  of,  526. 

tumors  of,  533. 
Pancreatic  duct,   406,   527. 
Pancreatitis,  acute,  operation  for,  532. 
Paracentesis    membranje    tympani,    122. 

pericardii,   307. 
Parasternal  line,   276. 
Parathyroid   bodies,   220. 
Parieto-occipital   fissure,   59,   65. 
Parotid  gland,   137. 
abscess   of,    138. 
Patella,    operation   for  fracture  of,   822. 
Paul's   tube,   470. 
Payr  and  Martina,  control  of  hemorrhage 

from  liver,   497. 
Pectoral  region,    lateral,   282. 
lower    anterior,    282. 
upper   anterior.   277. 
Pelvic   cavity,   687. 

floor,  682,  687. 
Pelvis,   floor  of,   682,   687. 
Penis,   amputation  of,   681. 

operations  upon,   678. 

surgical  anatomy  of,  677. 
Pericardii,   paracentesis,   307. 
Pericardiorrhaphy,   309. 
Pericardiotomy,    308. 
Pericardium,   283. 
Pericranium,    41. 
Perineal  fascia,  deep,  686. 
superficial,   683. 

section  with  guide,   689. 
without  guide,  690. 
Perineum,    surgical    anatomy   of,    682,    684. 

operations  upon,   689. 
Perinephritic   abscess,   operation   for,   659. 
Peritoneum,  parietal,  328. 
Pettit,   triangle  of,   325. 
Phalango-phalangeal   joints,   719. 

exarticulation  of  fingers  at,   720. 
Pharyngeal   membrane,   166. 
Phimosis,  678. 

operations  for,   678. 
Pia-arachnoid,   brain,   62. 

of  spinal   cord,   338. 
Pia   mater,    brain,    61. 

of   spinal   cord,    338. 
Piles   (see   "Hemorrhoids"). 
Pirogoff  exarticulation  of  foot,   782. 
Plate,   frontal,   164,   172. 
Pleura,   293. 

anterior  edge  of,  294. 

dome  of,   298. 

excision    of,    319. 

limits  of,   upon  chest-wall,  294. 

lower  edge  of,  296. 

operations    upon,    315. 
Pleurectomy,   Fowler,   319. 
Plica  epigastrica,   610. 

vesico-umbilicalis    lateralis,    610. 
media,    329,    610. 
Plicae   transversales   recti,    548,   550. 
Plication  of   gastro-hepatic  ligament,   360. 
Popliteal  space,  760. 

Posterior  nerve  roots,   division   of,   541. 
Poupart's  ligament,  325,  592,  612. 

space  beneath,   605. 
Preauricular  point,   44. 
Prsevisceral  space,  204. 
Prepuce,   dorsal  section  of,   679. 
Roser  method,   680. 

forcible   dilatation    of,    678. 

operations   upon,   678. 
Process,   frontal,   164,   165,   172. 

inferior  maxillary,   165. 

infundibular,   596,  597,  599,  610. 


Process,    lateral   nasal,    165. 

mastoid  (see  "Mastoid  region"). 

middle  nasal,  165. 

superior   maxillary,    164. 
Prostate    gland,    692. 

operations   upon,   G96. 

surgical     anatomy     of,     688,     692. 
Prostatectomy,   696. 

perineal,   698. 

suprapubic,   696. 

Young,   700. 
Prostatotomy,   Bottini,   703. 

Chetwood,    705. 
Pterion,   44. 

Pterygo-maxillary   region,    137. 
Pterygoid    plexus,    140. 
Pubic   ligament  of   Cooper,   604,   606,   614. 

portion  of  fascia  lata,   604. 
Pulmonary   valve    (orifice),   286. 
Pyelotomy,    661. 
Pylorectomy,    385. 

Billroth,   386. 

Rocher,   390. 
Pyloroplasty,   Heinecke  and  Mikulicz,   370. 

Finney,    372. 
Pylorus,   resection   of,   385. 

Recti,    ampulla,    547. 

pars  analis.  548. 
Rectum,   administration  of  ether  by,   8. 
amputation  of,   562. 
combined  method,   oSl. 
w^ith  establishment  of   artificial   iliac 

anus,   582. 
with  suture  of  end  of  sigmoid  to  anal 
margin,  586. 
perineal   route,   564. 
with  preservation  of  external  sphinc- 
ter, 569. 
with    sacrifice   of   external    sphincter 

(Lisfranc),   567. 
vaginal   method,   573. 
sacral   route   (Kraske),   581. 
blood-supply  of,   551,   583,   584. 
combined  method  of  operation  upon,  581. 
lymphatics  of,   552. 
operations  upon,   553. 

perineal  method  of  operation  upon,  564. 
prolapse  of,   5.59. 
operation    for     (see     "Sigmoidopexy"), 
560. 
resection   of,   562. 
combined  method,   587. 
perineal  route   (Dieffenbach),   564. 
sacral    route,    574. 
sacral  route  to  expose   (Kraske),   573. 
surgical  anatomy  of,  545. 
Regio     abdominis     lateralis     dextra     and 
sinistra,   330. 
epigastric,    330. 

hypochondriaca  dextra  and  sinistra,  330. 
hypogastrica,   330. 

inguinalis   dextra  and   sinistra,   330. 
mesogastrica,    330. 
pubica,  330. 
umbilicalis,   330. 
Region,  clavicular,  278. 
femoral,  604,  608,  612. 
gluteal,   750. 
infraclavicular,   279. 
infrahyoid,    216. 
inguinal,  591,  608. 
ischio-rectal,   683. 
laryngeal,    218. 
lateral    pectoral,    282. 
lower  anterior  pectoral,  282. 
lumbar,   322. 
mammary,  280. 
mastoid,  113. 
pterygo-maxillary,  137. 


836 


INDEX. 


Region,    sternal,   277. 

sterno-masioid,    208. 

suprahyoid,    216. 

suprasternal,  220. 

temporal,  40.  4.5, 

upper  anterior  pectoral,  277. 
Regional   anaesthesia,    14. 
Regnoli-Billroth  amputation  of  tongue,  226. 
Reid's  base-line,  44. 
Reil,  island  of,  60. 
Remak,  rachenhaut  of,  166. 
Resection  of  ankle-joint,  803. 

with    extirpation    of    astragalus,    806. 

of  caecum,  473. 

of  elbow-joint,   744. 

of  hip-joint,   817. 

of  intestine    (see    "Enterectomy"). 

of  knee-joint,   812. 

of  lower  jaw,  half,   149. 
of  entire  body  of,  153. 
of  half  of  body  of.  152. 
of  part  of  body  of,  154. 

of  pylorus   (see   "Pylorectomy"). 

of  rectum  .(see  "Rectum"). 

of  rib,   316. 

of  shoulder-joint,  746. 

of  skull,   temporary,   75,   76. 

of  temporo-maxillary  joint,  156. 

of  upper  jaw,   143. 

of  wrist-joint,  742. 
Retrovisceral   space.  204. 
Retziud,  space  of,   672. 
Rib,    first,    272. 

resection  of,  316. 
Ribs,    272. 

Right  lymphatic  duct,  226. 
Ring,   crural,  608. 

inguinal,    external,    325,    592. 
internal,   596,   610. 

umbilical,   347. 
Rolandic  angle,  66. 
Rolando,  fissure  of,  58,  65. 
Rose  position,  143,   189. 
Rose-Andrews,     extirpation     of    Gasserian 

ganglion.   111. 
Roser,   dorsal  section,   680. 
Roux,   gastro-jejunostomy,   458. 

Sacral   route,    rectum,    573,    581. 
Sacrum,  545. 
Sagittal   suture,   42. 

line,   43. 
Saline  infusion,  intravenous,  24. 
Santorini,  duct  of,  528. 
Saphenous  opening,   604,  753. 
Scalp,   40. 
Scapula,    332. 
Scapular  line,   277. 
Scaphenous  opening,  604,  753. 
Scarpa's  triangle,  754. 

operation   for  varicose  veins,   767. 
Schlatter,   gastrectomy,   400. 
Schleich  infiltration,  13. 
Sciatic  nerv^e,  stretching,  751. 
Scrotum,  599,  636. 

Sedillot,   extirpation  of  tongue,   267. 
Seminal  vesicles,  672,  687,  695. 
Serous  surfaces,  suture  of,  37. 
Shoulder-joint,    exarticulation    of,    deltoid 
flap,    739. 
Spence  method,   735. 
with    Esmarch    constrictor,    737. 

resection    of,    746. 

surgical    anatomy    of,    733. 
Side  of  neck,  204. 
Side-to-side    anastomosis    (see    "Intestinal 

anastomosis"). 
Sigmoid  flexure,   anatomy  of,   463. 
blood-supply  of,   583,  584. 
resection    of,    476. 


Sigmoid    sinus,    113. 

for  thrombosis  of,   126. 
Sigmoidopexy,  560. 
Sinus,  cavernous,  49,  56. 

frontal,  44. 
Killian  operation  upon,   102. 
operations   upon,    101. 
trephining  of,  101. 

lateral,   53,  55. 

longitudinal,  inferior,  55. 
superior,    54. 

occipital,   53,   93,   95. 

phrenico-costalis,  301. 

sigmoid    (lateral),   53,   56,   113. 
for  thrombosis  of,   126. 

straight,   55. 
Sinuses  of  dura  mater,  54. 
Skin-grafting,   306. 

suture  of,   33. 
intracuticular,  33. 
Skull,   41. 

anterior  fossa  of,  45. 

base  of,  45. 

dura  mater  of,  53. 

middle  fossa  of,   46,   105. 

posterior  fossa  of,  53. 

side  of,   45. 

temporary  resection  of,  75,  76. 

trephining  for  fracture  of,  72. 

vault  of,  41. 
Slip-knot,   23. 

Small  intestine  (see  "Intestine"). 
Smith    (Stephen),    amputation   of  leg,    790. 
Soft  palate,   134. 
Soft   parts,    division   of,    15. 
Space,   femoral,   606,  614. 

mesenteric  "dead  space,"  410. 

popliteal,  760. 

praevisceral,   204. 

retrovisceral,   204. 

subarachnoid,  brain,  62,  63. 
spinal   cord,   338. 

subdural,   cranium,   62. 
vertebral,   338. 

suprasternal,  204. 

vascular,  204. 
Spangaro's  incision,  315. 
Spence,  exarticulation  of  arm  at  shoulder- 
joint,   735. 
Spermatic   cord,    594,    634. 

fascia,    591,    636. 
Sphenoidal  fissure,  48. 
Spheno-maxillary   fossa,    141. 
Sphincter  ani,   external,   547,   550,   683. 
internal,   547,    549. 

dilatation  of,   553. 
Spina  supra  meatum,   116. 
Spinal   anaesthesia,   15. 
Spinal  column,  336. 

operations  upon,   537. 

cord,   337. 
dura  mater  of,  338. 
pia  mater  of,   338. 
Spleen,    excision   of,   536. 

flxation   of,    535. 

incision   into,   534. 

operations  upon,   534. 

surgical  anatomy  of,  533. 

for  wounds  of,   535. 
Splenectomy,   536. 
Splenopexy,    535. 
Splenorrhaphy,  535. 
Splenotomy,   534. 
Square   knot,    23. 

Ssabanajew-Franck  gastrostomy,   376. 
Staphylorrhaphy,  190. 
Stenson's  duct,   133,  137. 
Stephanion,   44. 
Sternal  region,  277. 
Sterno-mastoid  region,  208. 


INDEX. 


837 


sternum,  273. 
Stomach,   355. 

blood-supply  of,  358. 

closure  of  wounds  of,  380. 

excision   of.   384. 

foreign  bodies  in,   364. 

for  hour-glass  contraction  of.  382. 

incision  into,  364. 

lymphatics   of,    358. 

operations   upon,   360. 

surgical   anatomy   of,   355. 

for  ulcer  of.  364,  366. 
for  hemorrhage  from,  366. 
Stovain,  12. 
Stricture  of  oesophagus,  operation  for,  369. 

urethral,   perineal   section   for,   689. 
suprapubic   cystotomy    for    impassable, 
691. 
Styptics,  21. 

Subarachnoid  space,  brain,  62,  63. 
srinal  cord    "3-. 
injection  of  cocain   into,   15,  541. 
Subclavian   triangle.   213. 
Subdural   space,   cranium,   62. 

vertebral,   338. 
Sublingual    gland,    135. 
Submaxillary  gland,  211. 

triangle,     211,     262. 
Submental   triangle,   216. 
Superior   longitudinal   sinus,    54. 
Superior    maxilla,    130. 

operations   upon    (see   "Upper   jaw"). 
Superior   maxillary   branch   of   fifth   nerve 
(see   "Nerve,   fifth"), 
process,  164,  169. 
Suprahyoid    region,    216. 
Suprapubic   cystotomy,    674. 
Suprasternal  region,  220. 

space,   204. 
Surgeon's    knot,    23. 
Suture,   Gushing,   37. 

Halsted,   37. 

Lembert,   37. 

material,  33. 

of  bladder,   38. 

of  bone,    35. 

of  bowel,   37. 

of  cartilage,  35. 

of  heart,   309. 

of  muscle,    34. 

of  nerve,    35,   749. 

of  patella,    822. 

of  serous  surface,   37. 

of  skin,    33. 

of  tendon,   35,   749.  , 

of  tissues,   33. 
Sylvius,  fissure  of,   59,  65. 
Syme,   exarticulation   of  foot,   780. 

Talma's  operation,  499. 

Tampon  cannula.   Trendelenburg.  245. 

Tamponade   to  central  hemorrhage,   22. 

heart,   309,   310. 
Tarsus,    770. 
Tear-duct,  167. 
Teeth,   132. 

development  of,  170. 
Temporal   region,    40,    45. 
Temporary  resection  of  skull,   75.   76. 
Temporo-maxillary  joint,  resection  of,  156. 
Temporo-sphenoidal  abscess,   128. 
Tendon,   suture  of,   35,   749. 
Tenotomy  of  flexor  longus  digitorum.  765. 

of  tendo  Achillis,  765. 

of  tibialis  posticus,   765. 
Tentorium  cerebelli,  54. 
Testes,  descent  of,  599. 
Testis,  636. 

extirpation  of,  648. 

operation  for  undescended,   630. 


Thiersch,  skin-grafting,  306. 
Thigh,   750. 

amputation  of,   795. 

exarticulation  of,   at  hip-joint   (Wyeth), 
800. 
with    preliminary   ligation   of  common 
femoral,  803. 
Thoracectomy  (Estlaender),  318. 
Thoracentesis,    315. 
Thoracic  aorta.  292. 

duct,    226.    293. 

wall,    muscles    of,    274. 
Thoracotomy,    316. 

Lloyd,   317. 
Thorax,   271. 

aspiration    of,    315. 

fasci£B   of,    274. 

regions  of,  276. 

resection   of  wall  of,   318. 

skeleton   of,   271. 

tapping,  315. 
Thrombosis  of  sigmoid  sinus,  126. 
Thymus  body,  287. 
Thyro-glossal  duct,  135,  170. 
Thyro-hyoid   membrane,    217. 
Thyroid   cartilage,   216. 

arteries,  ligation  of,  for  thyroidism,  260. 

gland,  219. 
enucleation    of,    258. 
operations  upon,  254. 

partial  extirpatipn  of,  255. 
Thyroidism,    255. 
Thyrotomy,   248. 
Toe,   amputation  of,   772. 
Toe-nail,  operations  for  ingrowing,  775. 
Tongue,   135. 

amputation  of,  Kocher,  231,  262. 
Regnoli-Billroth,    266. 
of  a  portion  of,   266. 

clefts   of,    179. 

development  of,  170. 

extirpation  of,  with  preliminary  ligation 
of  both  Unguals,   265. 
with  division  of  lower  jaw,  267. 
Billroth,   269. 
Langenbeck,   268. 
Sedillot,   267. 

nerves   of,    136. 

operations  upon,   262. 
Tongue-tie,   135. 
Torsion,  23. 
Torus   uretericus,   674. 
Trachea,    218,    289,   299. 

operations  upon,   244. 

tampon  of,  244. 
Tracheotomy,  244. 
Transfusion,   for  severe  hemorrhage,   27. 

with  Brewer's  tubes,  32. 

with  Crile's  cannulse,   30. 

Carrel's    operation,    27. 
Transversalis  fascia,  328,  596. 
Transverse  colon,   463. 

facial  clefts,  168,  179. 
Treitz,  ligament  of,  407. 
Trendelenburg   position,    20. 

operation  for  varicose  veins,  767. 

tampon  cannula,  245. 
Trephine,    Doyen,    70,    86. 

Hudson,  71,  86. 

removal  of  button  of  bone  with,  78. 
Trephining.   70. 

for  depressed  fracture  of  skull,  72. 

for  hemorrhage  from  middle  meningeal, 
74. 

for  intracranial  hemorrhage,  74. 

of  frontal  sinus,   101. 

temporary  resection  of  skull,  75,  76. 
Triangle  of  neck,   anterior,   208. 
inferior  carotid.    209. 
lingual,   212,   263. 


838 


INDEX. 


Triangle   of   neck,    occipital,    212. 

posterior,    208. 

subclavian,  213. 

submaxillary,   211,   262. 

submental,  216. 

superior   carotid,    210. 
of  Pettit,   325. 
Scarpa's,  754. 
Triangular  ligament    groin,   592. 

perineum,   549,   686,   687. 
Tricuspid  valve,  287. 
Trifacial  nerve  (see  "Nerve,  fifth"). 
Trigonum  uro-genitale,  549,  687. 

vesicae,   674. 
Tropacocain,  12. 

Tunica  vaginalis  testis,  600,  638. 
Tympanum  (middle  ear),  118. 
Typhoid   perforation,    operation   for,    419. 

Ulcer,  leg;  769. 

stomach,  operation  for,  364. 
for   hemorrhage   from,    366. 
Umbilical   hernia,    347    (see    "Hernia,    um- 
bilical"). 

ring,  347. 
Upper  anterior  pectoral  region,  274. 
Upper  jaw-bone,   130. 
resection   of,   143. 
Upper    jaw-bones,    resection    of   both,    148. 
Upper  lip,    lateral    clefts    of    (see    "Hare- 
lip"). 

median  notches  and  clefts  of,   177. 

restoration  of,  201. 
Uracus,    329,    608. 
Uranoplasty,  192. 
Uretero-cystostomy,   669. 
Uretero-enterostomy,   671. 
Ureterolithotomy,   666. 

retroperitoneal  method,   666. 

transperitoneal   method,    667. 
Uretero-ureterostomy,   668. 

end-to-end,    Bovee,    669. 

end-to-side,  Van  Hook,  668. 
Ureters,    653. 

operations    upon,    666. 
Urethra,  677. 

bulb   of,   677,   678. 

membranous    portion    of,    678. 

perineal   section  for  stricture  of,   689. 

prostatic  portion  of,  678,  694. 

spongy  portion  of,   677. 

stricture  of,    operation   for,   689. 

suprapubic     cystotomy     for     impassable, 
stricture   of,   691. 
Urethrotomy,    external,   with   guide,   689. 

without  guide,   690. 
Uro-genital  diaphragm,   686. 

Vaginal    method,    amputation    and    resec- 
tion of  rectum,  573. 
process  of  peritoneum,   600. 
Valve,   aortic,  286. 
ileo-csecal,  462. 
mitral,  287. 
pulmonary,   286. 
tricuspid,    287. 
Valves   of   Houston,   548,    550. 
Van  Hook,  uretero-ureterostomy,  668. 
Varicocele,    operation   for,    638. 
Varicose  ulcer,  operation  for,  769. 
veins,    766. 
operations  for,  766. 
Madelung's,   769. 
Schede's,   767. 
Trendelenburg's,   767. 


Vascular  space,   deep  cervical  fascia,   204. 
Vas   deferens,    634,    638,    672,    687. 
Vater,  ampulla  of,   493,  518,   525,  527. 
Vein,   anterior  jugular,   206. 

axillary,    707. 

azygos,    288,    292,    300. 

basilic,    710. 

cephalic,    279,    710. 

external  jugular,   206. 

external  saphenous,   766. 

facial,   130,   137. 

femoral   (see   "Artery,   femoral"). 

hemiazygos,   293. 

inferior  thyroid,   221. 

internal  jugular,  121,  225. 
ligation  and  excision  of,  127. 

internal  saphenous,  753,  766. 

pulmonary,   300. 

ranine,   136. 

subclavian,  226. 

temporal,   139. 

temporo-facial,  137,   139. 
Veins,   hemorrhoidal,   551. 
Vena,    Galeni  magna,   63. 
Venffi    Galeni,    63. 
Velpeau  incision,   resection   of  upper  jaw, 

144. 
Velum   interpositum,   63. 
Ventral  hernia,  352. 
Ventricle,   lateral,   drainage  of,  98. 

tapping  of,  98. 
Ventricles  of  brain,  57. 

puncture  of,  for  diagnosis,  97. 
Vermiform      appendix       (see       "Appendix 

vermiformls"). 
Vertebrse,    dorsal,   272. 

Vertebral  column   (see  "Spinal  column"). 
Vesicle   of  forebrain,   57,   58,   162. 

of  hindbrain,    57,    58. 

of  midbrain,    57,    58. 
VesiculEe  seminales,   687,   695. 
"Vicious   circle,"    444. 
Visceral  arches,   162. 

clefts,    162. 
Vocal   cords,   218. 
Vogt's  lines,  75. 

Volkmann   operation   for   hydrocele,    643. 
Von  Bergmann  operation  for  hydrocele,  644. 
Von  Graefe  operation  for  harelip,   181. 
Von   Hacker  gastro-jejunostomy,   446. 

Wagner,  temporary  resection  of  skull,  76. 
Weber's    incision    for    resection    of    upper 

jaw,   143. 
Wellenschnitt,    Dieflenbach's,    184,    201. 
Wharton's  duct,  136,  211. 
Whitehead's  mouth-gag,  189. 
Wilde's  incision,   122. 
Winslow,  foramen  of,   493. 

examination   of  bile-ducts   through,    502, 
504. 
Wirsung,  duct  of  (see  "Pancreatic  duct"). 
Witzel  gastrostomy,   376. 
Woelfler,   gastro-jejunostomy,   440. 
Wrist-joint,     exarticulation     of    hand     at, 
Dubrueil,   726. 

resection    of,    742. 

surgical  anatomy  of,   775. 
Wyeth,    exarticulation    of    thigh    at    hip- 
joint,  800. 
Wyeth's  pins,  800. 

Young,   prostatectomy,   700. 
tractor,    700. 

Zygomatic  fossa,   140. 


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